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Please print or type.(Form designed for use on elite{12-pitch)typewriter.) Form Approved.DMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4.Manifest Tracking Number G R WASTE MANIFEST " 5.Generator's 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 Facility Name and Site Address U.S.EPA ID Number Facility's Phare- ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit HM and Packing Group(if any)) No. Type Quantity Wt'Nol. 3.Waste Caries 1, O t— a z 2 w C7 3 4 14.Special Handling instructions and Additional Information 15- GENERATOR'SIOFFEROR'S CERTIRCATION: 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationai 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 Cl 262.27(a)(if I am a large quantity generator}or(b)(if I am a small quantity generator)is true. Generators/Offeror's PrintedfTyped Name Signature Month Day Year 16 International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexil: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receiptof Materials p~.4 Transporter 1 PrintedfTyped Name Signature Month Day Year O rl rn Q Transporter 2 Printedrryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Ouantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manilesl Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z U) 19-Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1. 2, 3. 4. 20.Designated Facility Owner or Operator:Certification o1 receipt of hazardous materials covered by the manifest except as noted in Item Notice: State Of California req 11I C@S PrintedlTyped Name Signature generator to photocopy and mail to ar EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DTSC with 30 days: P.0 Sax 400 C -rnr,ng%,tn rA 95R12-0400