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Please print or type.(Form designed for use on a ite(12-pitch)typewriter.) Formcopy, 2050-0039 UNIFORM HAZARDOUS 1.Generator ID N mber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST : f:r l•,i;._: , .�"� !i `.i r r r G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing a dress) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.N01. 1. -'&'J bi »,; iii - LaS1+.I/.:..r:l.tl. ,:it l;dr:o iii -4* 1 Q LU 3. 4. 14.Special Handling Instructions and Additional Info mation ;� f\ ,N 1 2Htl t I f 15, GENERATOR'SIOFFEROR'S CERTIFICATID : 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all r pects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement i lentified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOffemes Printed/Typed Name Signature Month Day Year -J 16.International Shipments F-- ❑Import to S. ❑Export from U.S Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: Ell" 17.Transporter Acknowledgment of Receipt of Mated Is Transporter 1 Pr ntedf[yp�ed Name Signature Month Day Year a Z Transporter 2 Printed/Typed Name Signature Month Day Year rY F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quanti y ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Z Z N19.Hazardous Waste Report Management Method C ides(i.e..codes for hazardous waste treatment.disposal,and recycling systems) 7 0 1 s. Notice: State of California requires generator to photocopy and mail to DTSC 20 Designated Facility Owner or Operator:Certificati of receipt of hazardous materials covered by the manifest except as noted in Item 11i Within 30 days: rted/Typed Name Signature P.O. Boa 400,Sacramento.CA 95812'0400 EPA Form 8700-22(Rev.3-05) Previous editions ar R obsolete.