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Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14. ift chi be <br /> WASTE MANIFEST AR(TM7R711 t 7r; 516 S 71 F L E <br /> 5.GonerBMr's Name end A9ailing Add ross Generator's Site Address(if different than mailing address] <br /> Cajt`twNa Natural PrCrdur,I b <br /> 1250 E_ Ladym Reed ashtyrtn.aminatm-cord <br /> L.—Iitvop, CA 9&330 <br /> Generator's P110M <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> Adlrii Chemical lYars�sporf W.../DBA ACT(an%ire CAR13MC! 0540 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> LIS Ec do t�ks mda Ow. r IVIli'3, 11 C><!OG <br /> PO BOX =6k;,Ii Mitis ss Beatty <br /> Fleatty, NV <br /> Far;1111 Phone: 775-5,"-22W <br /> ga. 9b.U.S.DOT 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.Nol. <br /> 1-NON RCRA HAZARDOUS WAS-IT,SOLID(GRFASF) p 3621 <br /> 0 <br /> z 2. <br /> W <br /> (.7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Prriledt Nm]$EP 241304 Docur lertt MOMI <br /> 1) 071178300-2.015 CALL <br /> 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> 7nerator's/Offaror's Printed/Tyged Name Signature p r Month Day Year <br /> 16.InternAtional Shipments <br /> [= ❑Import to U.S. ❑Export from U.S. Port of entry/ it: <br /> E Transporter signature(for exports only): Date leaving U.S.: <br /> Lu rY 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> 0 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space [:1 Quantity ❑Type Residue Partial RejectionRejection <br /> Manifes!Refarenoe Number. <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> J_ <br /> V <br /> LL racitity'r;Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU G 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />