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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number sz 2.Page 1 of 3.EmeMTRespon�Plonel- anifest Tracking Number WASTE MANIFEST !l4�k02035 665 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) I 1 0 1+Ci+. ! r l" c1iZf t s~�r' P� 6'L F Il ld Mi5 C) earl, Cid f R1Pk#4, Generator's Phone: r f 6.Transporter 1 Company Name U.S.EPA ID Number !'1, if'. RE CCI!tFRY 15F P Tt:E5 , '=.r5.-A 7.Transporter 2 Company Name U.S.EPA ID Number g.Designated Facility Name and Site Address U.S.EPA ID Number fS,! VDi COVERy' SERVICE 1 t S' riIMS7t.LES, CA 10&3 Facility's Phone: (8(40) 4 q ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. • Z 2. l a. 1 t t _i 1 I � i , f q 4 f�11 3., i Y , _ i 4.' -i iii: , 14.Special Handling Instructions and Additional Information 13I-01' f S, 114MlR-f.S & lyROTEC I I VE CLOTHING "411P FE4ERGE11a77Y COW'i r T. V I K !4rX 6 1RV r,� ,2) Mrf' r-- "'` '�- I!f f!�!f11if►�I!I f f if f!itl!fllli llfli i�!!f f4�f!f!I!lfll 15. GENERATOR'SfOFFEROR'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 intemationaland 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 EPAAcknowledgment of Consent. 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. Gen re Offerors Printed/Typgd Name i' Sig _�.- '" ' Month Day Year 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials ^ Transporter 1 PrintedlTyped Name, Signature r' Mo th Qay Year CL z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ QuantityElT e Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number ' J ' U ILL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year ' z S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 . 2. 3. T- 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY I