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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 J J K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) J�% c. (rlt vltlrr /+<AILL. !LD 2L1y0 E k'fC�H+ Generator's Phone. i 6 Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA Io Number 8.Designated Fadl' ame and Sitt@Address U.S.EPA ID Number ;y rk- ...a ftaLO 1E. riii,VofV1E lA1 " .r ' YI115, CA 9.3*3 Facility's Phone: , ? Y ga 91b.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. W 3. 4. 14.Special Handling Instructions and Additional Information 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 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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true Generators/Offeror's PnntedlTyped Name Signature Month Day Year J 16.International Shipments j.._ ❑import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: 17 Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PrintedfTyped Name Signature Month Day Year O CL QTranspo ter 2 Pr nteC[Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue L1 Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL. Facility's Phone: Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 55 19 Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 13. 4. 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.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED)