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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 I'-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST It y'l I I 1 1 002184C"'464 JJK 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Rwho� 0 Kwbo ClovW NVIc'1"4 '0 A414 1%4'AW 8& 121"M '10119 Al 17'1 Sk,441i#i CA!)52W Generators Phone: %-JAIA2 6.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S—EPAiD`Number 8.Designated Facility Name and Site Address U.S.EPA ID Number (Ile tion t 15251 Old V�djlw Riwad Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Val 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. w 1- RQjhwa'tdmw Nro K.,9,"ftl'V) 111; (Sk A witil kwl �'1'20 u'4 il 2. Uj 3. 4. 14.Special Handling Instructions and Additional Information wtw Nowt k° 14 w-Urk HwAlifIR Wavimt 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully hnd 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 EPAAcknovAedgment 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 s Month Day Year 13 " 'IL I I Qq 127 LZ a16.International Shipments In Import to U.S. EIE.P.rt from U.S. Port of entry/exit:Transporter signature(for exports only): Date leaving U.S.: WX LU 17.Transporter Acknowledgment of Receipt of Materials �2 Transporter I Printedrryped Name Signature Month Day Year 0 CL CO) Z Transporter 2 PrinkidnOqOame Signature Month Day Year tY 18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity F-1 Type Residue Partial Rejection ❑Full Rejection Manifest Reference Number: It= 18b.Alternate Facility(or Generator) U.S.EPA ID Number Fiecilitys Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) M 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 Is, EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY