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Please print or type, Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZAR 3ouS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mta'n�lfest Tracking Number <br /> WASTE MANIFEST c.AI fltlrlf�3"aafirl f ;tE►��t t:it31 tJ : 8 23537 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> t U1.1-80y .INC. <br /> I S1 E ALMOIUUWOOD I:II<4V_ <br /> Generators Pho MAN I LCA,CA V60 3I <br /> 8.Transporter t Company Name U.S.EPA ID Number <br /> oWll1-ht LAH VAI-I.tV UVAbsf;ulL.,iW,; CAFtGtft3x`!ZY,12 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> j3 F MiC YC;;LL,W IL(JAL 11m VVAzi f tm;nAX i 1 Tl1 ti.INC f <br /> 8,Designated Facility Name and Site Address U.S.EPA I D Number <br /> ,!I:;I t;hNIURI' LNVIFM AIMENIAL MOM Q+ NEVADA LI.0 <br /> 2OU5IdEVVLANL7S l7ti. <br /> i'rRNL rY.W 11914168 <br /> Facility's Phoned �j. Aj vjgj <br /> ga, 9b.U.S.DOT Descnpti n(including Proper Sh'lipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouantity wivol. <br /> 1. <br /> p RO.t-9,+A077,HA,i°A17f'K)1,1%WASTIF.501,111.Mt'fti ,HRCI.111.1.FAf.1, t ��1+►\ � P 1lt,@fr� 1?i3f1Ti tf3i <br /> Z 2. <br /> W <br /> L.9 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> V1Kt*1LL.# tSbfi!Ja-Utf MHAi.; MAV rt�i:i it t1 i <br /> 1=Nlfrlit3�1�I4�Y L�1aC+lt+�t;I: tm,AAktTSlri <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contents of this cord9nment are fully and accurately described above by the proper shipping name,and are classed,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform tothe terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement idendfled In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ift am a small quantity generator)is true. <br /> Generator'siOfferorIs Pdodfpped Name Signature Month Day Year <br /> 116.International Shipments <br /> H ❑Impart to U.S. ❑Export from U.S. Pori of entry)6& <br /> x Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment ol Receipt of Mated e <br /> LU <br /> Transports Y <br /> r 1 Pr $ignat�ye � Mon D y <br /> wf& <br /> Transp r 2 PTintedrFy0bd Name �- Signature _ ._ MMh stay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ype ❑Partial Re <br /> ❑T Residue, jection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> W '18e.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems.) �- <br /> 1, 2. a. Notice:State of California requires <br /> generator to photocopy and mail to <br /> 26.Designated Fadllty Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC With 30 days: <br /> Printadrrypad Nama. Signature <br /> P.O Bax 400 <br /> Sacramento,CA 95812-0400 <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />