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`ease print or type. Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 Ge erator ID Number 2. Pae 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST � t a L133 97 r � 020427517 <br /> 5. G nerator Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> G a ® ` l1330 7 <br /> T' <br /> Generator's Phone; Rao r@60 "' Y07 ® � !j <br /> 6, n rler 1 Company a U S. SPA Num <br /> viber 1 7 1 <br /> �fPf�P11i1�T� � Og. . Inc. L� <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. I pd Site Address U.S. EPA ID Number <br /> 180 J. Monte Aventm <br /> Bloomln&n CA 92316 <br /> Facility's Phone: SW 421 e 2012 CAD982444481 <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 /> ® 1 ' 000 ACA� ® esus Ll J" t <br /> Ito <br /> <'01LS , DV ; 5C,X 7S) t 1 2zs <br /> f 1 <br /> 4, /t X + ) u5 Q ,yS 7t <br /> r6+9 AkE tewo04 �OeZw) <br /> 14 �Special Handling IW�cbons �AQditional Information q\ A4 ,LS qp ,5z , o z /y?6 / <br /> 3 AJ S`yc ck� b® x <br /> 15. GENERATOR'SIOFFEROR'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 generate ) or (b) lift am a small quantity generator) is true. <br /> Generator'slOffero dnted/Typed .Name Signat Month Dy Year <br /> a 7 Qr <br /> J 16, International Shipments <br /> f . ❑ Import to U.S. ❑ Export i S. Port of exit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> t p� 17. TransporterAcknowledgment of Receipt of Materials <br /> Transporter Pri a ame Sign re Month Da Year <br /> 0 <br /> QTransporter 2 Printed/Typed Name Signature Momn Day Year <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space Ouantity ❑ Type F] Residue ElPartial Rejection ElFull Rejection <br /> Manifest Reference Number. <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> tLar 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU <br /> 1 • 2. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted 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 TO EPA's a4AANIFEST SYSTEV1 <br />