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",ease print or type. Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 Ge rator ID Number 2. Pa e 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST ® � 3.� � ? °'�v � I^ 9y� 0 2 0 2 7 517JJK <br /> 5. Qonerator`5 Name and Mailing AddressG/ p C Generators Site Address (if different than mailing address) <br /> 0 .16A70 9 <br /> /33® ® . b <br /> Generators Pone: 904o @60 ^ Y® ? , <br /> 6, nspgrter i Company e , US. SPA fNu,Cnber 1 7 1 <br /> �ivr1i3TTt$ � a , (tib. e E{ E� <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8. ' " rend Site Address U.S. EPA ID Number <br /> ISO €ate Avenue <br /> Bloomireton CA 92316 <br /> Facility's Phone: SO 421 = 2012 C A D 9 8 2 4 4 4 4 8 1 <br /> ga• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) 13. Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> ® ' � ® ,� ACIPL Doul Lt Qj c 1) <br /> 2. /zG /ZD$vS &M r < c <br /> 1 '01 LS , byts 56x e 7S) L ZS (s <br /> 3. f�-CI rZ� d6'S FL) ff l <br /> 4. uS 4l "1 7t .S"®e i� <br /> (6f 9 AkZ <4 �� �� l 1� <br /> 1 Special Handling I !ructions and difional Information <br /> � �. °z sem' La) A4tt S ® �� -� ���o /v® <br /> Z> k) ttL ClV76it) <br /> 3 tit 9`4 gr$- �® x <br /> 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, <br /> marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary <br /> Exporter, i certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generato ) or (b) (if i am a small quantity generator) is true. <br /> Generators/Offero nntedfTyped Name Signat a Month pay Year <br /> 16. International Shipments <br /> r ❑ Import to U.S. 0 Export f S. Port of a xit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> tail 17. TransporterAcknovdedgment of Receipt of Materials <br /> a— Trans iter 1 Pn�.99ii��dd����a ame <br /> po C� �_ Sign re Month Da Year <br /> 7 z® <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 9 <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space quantity ❑ Type 0 Residue 0 Partial Rejection 0 Full Rejection <br /> Manifest Reference Number. <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> r <br /> U <br /> u Facility's Phone: <br /> LU 18c. Signature of Allemate Facility (or Generator) Month Day Year <br /> 4 <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> ® 1 . 24 3. 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY I O EFTA's onMANIFEST SYSTE110 <br />