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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2. Pa e 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CA V3 L/7/ 4f Y� 1 020427507 5. enera is Nage and Malin d re C L Generators Site Address (if different than mailing address) / 3.3 ® � *44 ! Z6 Generators Pflone: �� 7 s. AVITa i�Ti Company Log. r 11104 U S. F A AN,61eb 1 7 5 1 7. Transporter 2 Company Name U .S. EPA ID Number 8. rpd Site Address U.S. EPA ID Number ISO Ww Monte Avenue o ingon CA 9016 Facility's Phone: `�` " 21 2 D 9 B 2 4 4 4 4 8 1 gal 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 11 LU LU 2PO/? 1� � �Dt /S Sdec 3. 4. 14. peciai Handling InsW tions d Additional Information Z ) PAS ) , Awl 9� s fdn s� 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational 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) lift am a small quantity generator) is true. Generators/Offerors Printedityped Name Signat 1 Mo /Day Year r 16. Intemational Shipments ❑ import to U.S. ❑ Expo m U.S. Porttry/exit: Transporter signature (for exports only): Date leaving U.S. : W 17. Transporter Acknowledgment of Receipt of Materials H Transorter 1 Printed/Typed a Signature Month Day Year L , S � � �e � l 7 1 / 11 12o0 Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: r 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V u. Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year B Z 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 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 Printedfryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 112w17) Previous editions are obsolete . DESIGNATED FACILITY TO EPC 's G= A IF ST SYSTENq