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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 45. NIFORM HAZARDOUS 1.Generator ID Number 2.Pa7o, mergency Response Phone 4.Man'rf T kl Rh A WASTE MANIFEST rr Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) MAR 3 r' 2 6 rt , ._ t �.7t F ask, 4 1 rM +11-')I`-' btu,.1.5 REVIEWED Generator's Phone: :::7 ?`-c`i.rcc 6.Transporter 1 Company Name U.S.EPA ID NuMber- - r 19 7.Transporter 2 Company Name OEM hM the cip) U.S.EPA ID Number permits for and will accept 8.De%pted Facility Name and Site Address U.S.EPA ID Number h r� ,r.:. the waste this generator Is .:"' %0984i 11 65.5'WH'FE E R£1'"K RO. c-,A,N Hsem;�.ORLX"t A, CA 9670 , shipping. Facility's Phone: 4'1 9a 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.Nol. QQ, 1• ast.9 C; rro&•e bq,.ki,ri.l ,$ , ��LU W 2. t 3. 4. Ni,tl•sat CF,4`,H vt ' e4'a�r° Stt I tC{LiiLy, ��lttl t$�v '* w a, e ti i t 4.Special Handling Instructions and Additional Information ACID LAO PACK ERG J. ERG 7 , 71,5. GENERATOR'SIOFFEROR'S CERTIFICATION: I 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 respects 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 Identified 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's/Offeror's Printed/Typed Name Signature Month Day Year -J 16.International Shipments O F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transportw 1 Printed/Typel Name Signature - Month Day Yeah CL Z Transporter 2 Printed ped Name Signature Month Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity' ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V ti Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � t 2. t � 3. f 4. t 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedrryped Name fj tt �` Signature i Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR