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i ( je e Piease print or type. (Form designed for use on ell te (12•pitch) typewriter.) Form Approved, OMB No. 20504039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. EnlergencyResponse Phone 4. PhriifestTracking Number WASTE MANIFEST ^; L 0 0 d a 7 9 1 7 ' 1—01 � !r a3�4f78 016171191 JJ K S. Generator's Name and Mahn Address Generator's Site Address Cd different than malting address) VALUE PRODrUCTtIRIC. 2128 INDUSTIRJA . tSRla E 21T I:dDt1$ir kL ORVE LTOCt TU'NI CA 95205 15TEICXTON r A 952 Generator's Phone: 6. Transporter 1 Company Name U.S, EPA ID Number E r CAP000 i 89 Q 1 .J . tl iii• F.a .. 7. Transporter 2 Company Name U.S. EPA ID Number 8, Des` ated Facility (Name and Site Address U.S. EPA ID Number �Fitt4'H�,A 1rr.P �TE 55251 F ftn SKYLINE R0. KE11F.EWAN, C4TW, 1n FFG S Fau1i s Phare C T Q G 0 5 � t7� t 1 7 ga 9b. U.S. DOT DesVptan (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12 Unit HM and Packing Group (if any)) 13, Waste Codes No. Type Quantity WtNoL y 1 . ( iNi 1? ; �fi TL ` t ai►ftbt F�t`_!FO� f± fc '_''�t �i [>~rs, $, PC=1t f d t �i1 Z 2. ate 1 �•_ , E� !itl 9tt C�CREr-IEEE, vI��ICtj 1��t E!s C, i . -PGII � t31 D 11 1 � 3. t 4. ! p 14. Special HandAro1nsfnrc w s and CORR5IVAdditional hormatlon 5LLIIDGE ERUW 96 t . IE4j BE.. 164 c. v_ ,1 I Ee. C 3fSi� S.;.��.�it�3° "w . t !� �� I F c -. � + rd +ti a: T�� j • •L r, r, . t 22' 1 CA€1 '`a-- INyfltiTRLA. D=TEkCEfU 1 Cf.�F€Rn. ciPdE 24 HFtiE' tRr7E(`dC ' CONTACT a' Et s`IR0 ERN, 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fLdt and aocuratelydescribed above by the proper shipping name, arca are classified, packaged, marked and labeled/piacarded, and are in an respects In proper condition for transport according to applicable international and national governmental regulations. If export shi nerd and i am the Primary Exporter, I certify that the contents of this constgnment conform to the terms of the attached EPAAcknowledgment of Consent. I certifythat the waste minimization statement identified m 40 CFR 262.27(a) Of I am a large quantity generator) or (b) (if ] am a small quantity generator) is true. Generatoesl0fieror's P edlTyped N e Signature Day Year Cz� Pei 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 LW 17. TransporterAcknowledgmentofReceiptofMaterials ort �t. ante hyped are SI Month Da Year QTransporter 2 Pdntbdrryped Name Signature Month Day Year ixF 18, Discrepancy 18a, Discrepancy Indication Space ❑ Quantity F] Type El Residue ❑ Partiai ReJedion ❑ Full Rejection Manifest Reference Number. 18b, Alternate Facility (or Generator) U.S. EPA ID Number V [fie. Facility's Phone: w i8c, Signature of Alternate Facility (orGeneratar) Month Day Year Q Z S2 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 20. Designated Facility Owner or Operator, Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledlTfped Name ! W Signature Mon �D�y Year EPA Form 8700.22 (Rev. 3.05) Previous editions are obsolete, ' `-t ll DESiGMATS® FACILli Y 'Tai DEST6NATI©Mb STATE (St^ REQUIRED)