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Please print or type.(Form designed for use on elite(f 2-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 `0026 P.1371 002182419 J 5.Generator's Name and Mailing Address Generator's Site Address(f different than mailing address) Vit$'E$1z •1 �P;1't;rt°� "5 i S# t };o0 NVWflh "J" °fYlil arse.[icata ;,A 0'-N�, Generator's Phone: 81 ,1 41:,}.v ' 6 Tra%porter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility gName and Site Address U.S.EPA ID Number Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. 12f.: , rtit��ftar+s°.t f<t .6I x xs tttr 3 eras cr 440 s,1 i L �4�,). .s y1f 1'ktirr 1"3 111, ( }j 1l`I' (13 )t) r' t_` whit (°'t . .;r 0 14210 z' 2. L C9 3 4. 14.Special Handling Instructions and Additional Information Pft Wile R it)Q 1A'99)'80 F11(14 t-)!'I I 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 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. enerators/ ror's Printed(fyped Name Signature qq { Month Day Year .t 16.Intemational Shipments F- ❑import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials a Transporter 1 Printed/Typed Name Signature Month Day Year ZZ Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity [:]Type 1:1 Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: i 18b.Aftemate Facility(or Generator) U,S.EPA ID Number I J i FaciliVs Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) l 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnted7yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY