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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.Manifest Tracking Number WASTE MANIFEST CA-( 000 y 8Sr7 I 19�jrm--� Zl(Q s Orb 017 6 8 0 3 0 2 JJK 5.Gnat r plame apd Mailing ress Generator's Site Address(if different than mailing address) 91� FiP�UV R 6ATf1RoP Generator's Phone: 2Q 47 1 C 2- 6. 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated F ci' Name ap Site dress / U.S.EPA ID Number IMAX d �' � C/ � air s Facility' n /d�b ch I- O oQ 1-3 9a, 9b.U.S.DOT Descdption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1993, C�n�us�ieEi,L,'c�U/D/ � -rp 1 2�3 Pti >/ W 1 LU 2#A 3. 4. r i 14.Special Handling Instructions and Additional Inforryation PPS' 26 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 C nsent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or( f I am a smal rator)is true. Gerler is/Offemr's Printed/Typme Sign ture Month Day Year T O�P .V/ n7 iISi 2D -J 16.International hipments z L-1Importto U.S. ❑Export from U. Port of en ry/exit: Transporter signature(for exports only): Date leaving U.S.: W17.Transporter Acknowledgment of Receipt of Materials Transporter6tAp nted/Tyed ame � Signature Month Day Year 'a V U) 7- 1 QTransporter 2 Printed/Typed NameSignature Month Day Year tY t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U M cc Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be \ PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED