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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1:of 3 Emergency Response Phone 4.Man`iifefstt Tracking Number WASTE MANIFEST ;�! ,}rRtJ LP 2 G B F 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) it r. 14 I'd 1441 I •''gwls.l11 f Generator's Phone.,'t e9 "C31 b2 r 6.Transporter 1 Company Name U.S.EPA ID Number r�tit�Ir..�tst.:�',i'J iJ!y! i i, � t: 06.. 04.' �.;.=ia.;�Jtls>i I•t 7.Transporter 2 Company Name U.S.EPA ID Number ;,if 1'Y L4'/311- 8.Designated Facility Name and Site Address i itr Hilt ,�i 1.4,6;t 141°rjA i it ir'.I:,'U;.;;; U.S.EPA ID Number f 1i. Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes No. Type Quantity Wt.Nol. w4�Lrl.ltiiv,gF4. i�p >intl JtJi:. i W 1 Z 2. W 0 w 3. 4. 14.Special Handling Instructions and Additional Information 1`ft 4it.i::F y r'ii 11.' if'.:''illt.t�1%,A i.At4.. k3as..idy : NIAWY 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 genbrat�F)or(b)(if I am fsmall quantity generator)is true. Generator's/Offerors Printed/Typed Name Sig(ta re Month Day Year , J 16 Internatwnal Shipments rd Or Import to U.S. e Z ❑Export frorr�U. Port ofentry/exit Transporter signature(for exports only): Date leaving U.S': Li 17.Transporter Acknowledgment of Receipt of Materials Transportert;pri ed e )�ame Signat re__ *. "'_ Month Day Year YX Ji a �r J �, QTranspo er 2 Prin ed/Typed Name Signature 1..`*~ M t` , Month Day `'Ye6r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑ Full Rejection Manifest 18b.Alternate Facility(or Generator) Reference Number: U.S.EPA ID Number J U LL Facility's Phone: UJ 18c.Signature of Alternate Facility(or Generator) ~Q - Month Day Year Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes foe hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. -- Notice: State of California requires 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a generator to photocopy and mail to Printed/Typed Name Signature DTSC with 30 days' P.O Box 400 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Sacramento, CA 95812-0400