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PleEkse print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number WASTEMANIFEST I 1 1 0,02182450 JJK 5.Generator's Name and Mailing Address Gep47 Ues ress(If different than mailing address) RIZAti, hwj' U0 ' VISVIOIN 111A ;'011) ' I I 41110'iSIMKk * ,'K U CI M A I'N F04 WCOM ,'I'X Generator's Phone: P1 idid" 6.Transporter 1 Company Name U.S.EPA ID Number Z r4 1Q.9:! C 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number 0winkmI wvwfi"° 357-51 CAd'Skviiw,fl#;wl 'A'I'I KK�t Ao I I Kviticulmi 011y,(,A 93)11' -Va10 11 Facility's Phone: 9a, 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 V.Q, N 0�8,9,1 0111*14?7< Ips;III, ttftl Uff f J"'N't I V (11"Ami widl lfxwj , 170 pjwf) Z 2. Uj 3. 4. ---------- 14.Special Handling Instructions and Additional Information VR 0171 wcff¢::g.:g'`': 1-44"wNms J-himWip"I 1AAa-iol 15. GENERATOR'SIOFFEROR'SCERTIFICATIOK- I hereby declare that the contents of this consignment are fullyand 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 iniiiinationai 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. Generatorst0flanor's PrInteilrryped Name Signature Month Day Year C,A A3LA Al G-a: 122 1;6 1 z -i 16.111lemalional Shipments F- 1-1 import to U.S. H Export from U.S. Port of entry/exit: 3 Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials 7 UJI 12 Transporter 1,PrintedfTyped Name Signature Month Day Year 0 Z TrarWiter-2 Printedfryped Name Signature Month Day Year 18.Discrepancy 16.Discrepancy Indication Space 0 Quantity ❑Type El Residue F-]ParU.1 Rejection El Full Rejection Manifest Reference Number. 18b.Aftemate Facility(or Generator) U.S.EPA ID Number LL. Facility's Phone: uj 18c.Signature ofAftemate Facility(or Generator) Month Day Year !R 1 Z USCD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj1. 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY