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SSP 4 2019 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. Emergent Response Phone 4 Manifest Tracking Number WASTE MANIFEST J -J 3� x f 5 Generators Name and M iling Address Generator's Site Address (if different than mailing address) >ti Generators Pt o ear . ' .ice �j 6. Transporter 1 Company Name U.S. EPA ID Number 7, Transporter 2 Company Name U.S. EPA ID Number. 8, Designated Facility Name and Site Address U S. EPA ID Number Rico 'ODA IvAll 1620 E . RRUN M 11B Facility'sPhonw. 3071-30i.k CA Q3147. 99 90. U.S. DOT Description (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.Noi. ICA NC ON CT A KA7A F I NIT JS WAS ut e ( W 2. : 4. } 14. Special Handling Instructions and Additional Information 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, arl 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 Pnmarj 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(x) (if I am a large quantity generator) or (b) (if I arr a"soall quantity generator) isifue. _ Generators/Offerors Printed/Typed Name Signa�ure ear; r Month Day Year f .. r ; 16. International Shipments t H ❑ Import to U.S. ❑ Export from U.S. Fort of entry/exit: Z Transporter signature for ex orts onl ate leaving U.S.: P 9 ( P Y)� / � 9 w V. TransporterAcknowredgmentofReceipt ofMaterials ' Transporter 1 Pintedrryp d Name Signature / Month Day Year A du Q Transporter 2 Printed/Typed Name J Signature J Month Day Year 18. Discrepancy 18x. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection YP j ❑ Full Rejection Manifest Reference Number: �- 18b. Alternate Facility (or Generator) U.S. EPA ID Number � i v - J rai Facility's Phone. / l7 w 18c. Signature of Alternate Facility (or Generator) Month Day Year . i- z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardouswaste treatment, disposal, and recycling systems) 2. 3 4. 20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the-knanrfes wei{cept as nct�ed in Item 18a Printecirryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. - -- -