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Please print or type.(Form designed for use on elite(12-pitch)triter.)pewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number JJ K WASTE MANIFEST z' 's, i.'r.: .'::' 0 0 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name r U.S.EPA ID Number . e S 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and SitgAddress _ U.S.EPA ID Number i f�y Facility's Phone: 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('d any)) No. Type Quantity Wit./Vol. � 1. o}_-s,}st }4.3"� �ld �, a111. . 0 - - � LLI CW9 ttt.�' h 3. .`Iha:F, 4 14.Special Handling Instructions and Additional Information k: e ,ir _3 + A4KC';it:i V� f!; p,— TM_.577 at 4i'i ll_ #P0 rP,(AIL BASE P'`1N'l w ER 1?0 Wd-PW? 1:Al141't, ��e1i►�dC. SP�i1.1i'r 15. 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. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year 16.International Shipments I— _ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials tj Transporter 1 Printed/Typed Name Signature, Month Day Year, QTransporter 2 Printed/ryped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial ❑Residue Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year t20. S29.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2' 3. Notice:New federal form. State of California requires generator to photocopy Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and mail to DTSC within 30 days: rinted/Typed Name Signature P.O.Box 400,Sacramento,CA 95812-0400 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY