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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I t-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST •.1:%"c.:+^:;Ui,.r:5t' G B F 5.Generator's Name and Mailing Address Generator's Site Address(lf different than mailing address) ':;at}C;IRfEL?TRAC:'ft'3fii ;3Fili il'dC. +:i,�;i IBJ l`.�4ARTFR WAY Generator's Phone: ' 6.Transporter 1 Company Name U.S.EPA 1D Number `iAULL VVA6TL.. :_!: , ISH; . •. 7 Transporter 2 Company Name U.S.FPA ID Number S Designated Facility Name and Site Address U.S.EPA ID Number I=�lA't!t.�;z'v6rA,�;I E. I!!F"J�,i°C•V aac;f f I#y. Facility's Phone: 93, 9b,U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WLNoi, �. 1' w w � [7 3. 4. w l 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuily and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacanted,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 EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 21(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslOfferor's Printed/Typed Name Signature Month Day Year J 16.international Shipments H ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: CC w 17,Transporter Acknowledgment of Receipt of Materials Transporter 1 PriniedlTyped Name Signature Month Day Year 0 a 2E Transporter PriniedlTyped Name Signature Month Day Year 9 i- 18.Discrepancy 1 Sa.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑FuU Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J Facility's Phone: In 18e.Signature of Alternate Facility(or Generator) Month Day Year a M y19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems} LU o '' 2. 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials Covered by the manifest except as noted in Item 18a DTSC with 30 days: Prnledlryped Name Signature P.Q Box 400 Sacramento, CA 95$12-0400 EPA Farm 8700-22 112-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY