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.1 • Please Pint or e. Form designed for use on elite(12-pitch)t ewnter.) • Form Approved.OMB No,2050-0039 P type.( 9 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ;,. ', < a, 0 0 1 401r'34 JJ K 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) £ 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 Facilit,Name and Site Address U.S.EPA ID Number 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(if any)) No. Type Quantity Wt.Nol. � � t ..� s 1i�`�.t4.�;':i.j�.� +!z z f._ ., i j�){.£'"•tk st '.::�:�_�7_�.za•., . ..,�'t ... . . pa.'. f. .... :� f } 1`P41if f4t(kaa Z 2. LU 0 3. 4. T-1 4.Special Handling Instructions and Additional Information 15. GENERATOR'SfOFFEROR'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 intemational 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/Offerors Printed(ryped Name`; r' Signature Month Day Year .: 16.International Shipments "J F ❑Import to U.S. ❑Export from U.S. Port of enby/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(ryped Name Signature Month Day Year OCL s" ,.:• QTransporter 2 Printedr typed Name Signature' Month Day Year H 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 I Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.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 20.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: PrintedlTypad Name Signature P.O.Box 400,Sacramento,CA 95812- 0 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY