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Please print:or;type, Form.Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNI kRM HAZARDOUS '15,14247 <br /> ^p C <br /> WASTE MANIFEST GA1114 4�'}4t3 $ two'0 6 41 � B <br /> 2 7 G <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> j.MUM 01110 IW' <br /> W 0 VV,C;MARTER WAY 948 W UTART1 R 114AY <br /> 8 VKTON,CA 05206 <br /> y.,. fsRr ($g1a <br /> Generator's Phoria: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> .("�tt�$.";1'1,1�F1�I53 �'t�.�.,1`::�'�6i�;;�6 h;),01L,$.t�tG:. zul4RI:#OTI�7:,2"Xr-1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> p ,1E1,i):ICY(,'1 _;','PFGAAL'VY' tAM1ti�"E Sti:LVI4C)N$,dt`e" . 1,150;01'€OWN <br /> B.Designated Facility Name and Site <br /> - Addresrit 87 t:'��, ifiW 1'LYVjl1'?.vW4 r' t4 A L YYWIi tP WIY¢G' A. 0a US.EPA ID Number NW <br /> }P 80 8 96M41 <br /> 2095 Nr'iitti,lNOS rk,EM� <br /> Facility's Phone, t <br /> 9a, 9b.U.S.AOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol, <br /> R P£X'd16,1,§~AP,3, 1 M14 <br /> All It Irf <br /> 2 <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> 'ki,4061,V-00 P+4'F""AALS14AflWt•S 'l5cl L"Rk '1;/1 <br /> C(,)WVu:CT! ALLEW <br /> �f <br /> 15. GENERATOR'SIOFFEROWS 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, <br /> marked and labeled/placarded,and are in all respects in proper condit€on for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowlecil of Consent. <br /> I certify-that the waste minimization statement identified in 40 CFR 282.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOfferor's PrEntedflyped Name. Signature Month Day Year.. <br /> 18.internationihipments <br /> F <br /> El Import to U.S. ❑Export from U.S. Port of entrylexft: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> Ce 17.TransporlerAcknowledgmenl of Receipt of Materials <br /> Transporter)Pri;dffme W Signature P Month Day Year <br /> ! <br /> Trans'rte 2" ame µ.Sig Suture M h y Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejectien <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> C7 <br /> Facility's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day. Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(La.,codes for hazardous waste treatment,disposal,,and recycling systems) <br /> � Notice: State of California requires <br /> 1. 2. 3. i generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certificatlon of receipt of hazardous materials covered by the manifest except as need in Item 1Sa DT with 30 Q>1ayS: <br /> PrintedlTypad Name Signature P=0 8mx 400 <br /> 5=arnento, CA 95812L-0400 <br /> EPA Form 8700-22(Rev,12-17) Previous editions are obsolete. GENEiAr® NIVAUVW ' <br />