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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 MANIFESToff 1�C A(,UQ62 1'V7 00218,02426 JA 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) m-3g,�, Ra4w ,3�'k 10#0 kadu)S3,rw--,k &I" t,lA Q AVI-1 I I'i`O I�,4�Yz 1, -N1% I?l I Ftwt Generators Phone: 6.Transporter I Company Name U.S.EPA ID Number �-c 7.Tran goort&2 Coma am U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 4111-�rfli'-A WAsle "A 104�,R4;1 I 4'ifv,CA 9`,V23") 11 Facility's Phone: 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)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. RO, Si4r' 0 f�x1l 41111 10 t 20 n o Z Z Uj 3. 4. 14.Special Handling Instructions and Additional Information 4f' c' ':44( 4t Ili+ w6on 14"do111ily., 15. GENERATOR'SlOFFEROR'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 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratoestOfferors Printed/Typed Name Signature Month Day Year F')t 'A(',',i- 10`�- A L i I, 16.International Shipments 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LU po 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month, Day Year 0 A Z -T&rp.de,2 Pr)hWyped Name,.. 'Day < Month `year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity 11 Type El Residue D Partial Rejection EJ Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year !R Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 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. GENERATOR'S INITIAL COPY