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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ' :f-•. h:i tt 13ar5 ..- O. 2 3 2 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) l i3AMOS.CigVIRl7WENTr'!_GEK tiara INC., P.G. BOX A04 11515 RNiER RD. -VEST;a"GIRtAA�igT0.GA yf,t"?i r'!"k3'f�.�.i:P$htf htF�,4"W1. 12,%9.1 Generator's Phone:,.,;:-__; ;..=;;� _, 6.Transporter 1 Company Name U.S.EPA ID Number s{r PriCl S ar>1F tat tLarTr�L SERVICES INC. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number iKr`,iy{t';g EId\•'3Ft4.Sitfe`vii^iw''ir1L :�Ir�'t,4CES INC. 1515 SIOUTpi Ri11FR Pn- rwA. rI �fi�Lw I&F-G-T 13ACR,4,McWM.CA gn-69i Facility's Phone:':ri f•-•�'',•: ;':j" 9a. 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. NON RCRA HAdr.i•ii:+aus vJ.s',,a`m l.,fo la(1.11;=11:D ni!) W Z 2. W L) 3. 4. 14.Special Handling Instructions and Additional Information991)USED 01L.NUE6 UL F.nm ; JCA _ w :':..1 t`i�•'f',i dr f'^�.�i 0 6 1 - W,Nf3LERS'I'D BE TRAINED:AiNi3;,;SE APPROVED Pi'fr. t=.R. 001KifRAC'TOR: RAA1AOIS i-I'it/I"�'l3Pit v1�i"'i�.L 3ER':11ceS 15. GENERATOR'S/OFFEROR'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 EPA Acknowledgment 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)(ifl am a small quantity generator)is true. Generators/Offerors Printed/Typed Name Signature ry Month Day Year J 16.International Shipments ZE]Importto 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 w r- Transporter 1 Printed/Typed Name Signature Month Day Year O y Z Transporter 2 Printed/Typed Name Signature Month Dayr Year r- 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 U LL Facility's Phone: LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1' # 4 2• 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nctod in Item 18a Printed/yped Name , Signature Month Day Year r,. 2��.:it y'r 4 u a"./i re�d :,, .r' 1✓f%'��g dr•"•', �;3 • EPA Form8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY COPY IF YOU RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE P.MANIFFST Ar.T AFF IM.RTPl IrTinmq not PrwPPcr Qinm