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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 4.Manifest Tracking Number <br /> WASTE MANIFEST °A1•i3t32rif*97#f " GBF <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing a ress <br /> til WtILAX.)k3taCstt'tE:l '1"1�tlt11�#td <br /> '16SW 8 TRACY tai,VIJ <br /> Generator's Phonsr ca,. 'me <br /> r' # c <br /> 6.Transporter 1 Company ame U.S.EPA ID Number <br /> AhA1.fftI0A14 VAI LLY VUK0 4'01L,INC, CA1x1X1f1;?%�1302. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Vd(-3III- iVYIII)V.1'ff::Q0V€,Ry >y iI t!fO ;#t it; CAh'OVYI7`i4:Y.-'. <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> YtJIMA y't:;ivS 2 VVA:a t k. f f3A 4`it•1 3t 1"A #1,#i Y A7.1100052 11413 <br /> 660t.}US,rti(41UltAY 145 <br /> YIJMA,A7 4636SFacility's Phonef)2Lt-J44•u�i 2 <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> O ?4()1`t.•tp{ tart#1A 'A ()CA I-N VkIAI!,1'F 't)i•f(l A€ ;t} 13 h1T? PACT fit/'0 # 1)ttti 'tti i� <br /> .'ie7�,? <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> f 1 <br /> 14.Special Handling Instructions and Additional Information <br /> }"'#�'�i�11.3Ji Ittt;,#?+811P1P�;; I�'Atak:t"i f'f#.1•Mki t�t�.c I'}''1 . <br /> i.:-. ikiRGE Ott,i'0011 TA J: JOL <br /> 15. GENERATOR'SIOFFEROR'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)(if I am a small quantity generator)is true. <br /> Generato sl0fferor'sPrinted/Type Name Signature Month Day Year.:3 <br /> f , ZI'-;iY,,,7,"`°�r�r ✓,,, f J r r'..J7 Lff .bf.rH p�`t'.!'''r LJ' .`"rJ <br /> 16.International Shipments <br /> I- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> oTransporter 1 P ecl Typl�Name µfig Signature,--- Month Day Year <br /> Transi`orter 2 rinted/Typed Nerp `Signaetu ..- ''r. " " Month Day Year <br /> r- h� <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej El Full Rejection <br /> ❑Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C) <br /> 11. Facility's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> L 1. 2. 3. Notice: State of California requires <br /> generator to photocopy and mail to <br /> E <br /> ated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a @ p";' ;?Si9fl'h GJ <br /> ped Name Signature jy. vl)it/1,00 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. C9r5NE'RA`R'1 R'S 111111A Cot�@� <br />