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Please print or type Form Approved.OMB No 2050.0039 <br /> UNIFORM HAZARDOUS 1 GenorlriIgrpr� <br /> 2 gage 1 of 3 Etgon a Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 0 OHM35 2 5 GBF <br /> 5.[venerator's Name am Mas1.ngAddresi;j 0r K I(.)N EAS] �VA I k;P, 111;+i file] Generators Site Address i.I different than mailing address) <br /> filfi! L. II _ <br /> 2'Jt1 U.i.t•l!?rc1 <br /> Generalors Phone. <br /> 6 Transporter 1 Company Name i..MLI lj(,AN VAL.I jr-Y W1:`�i h��IL till. U.S.EPA-D Numoer i,AI1t)(9I2J2:;U2 <br /> 7 Transporter 2 Company Name F S EPA ID Namocr(;ARtJ1Xf{7'A'':) <br /> 8 Designated Fac.ty Name and Silo Addressv(1S„lA 11 VVI%.,I L- I filth 1-t-1: 1 At..11 111 V 5 EPA ID Number <br /> r,;aj(ill:,f fl0fr1;A-r IJ;� <br /> 11�14(11l(I�,_1148 <br /> 711%11,A; <br /> Fa=lily's Phone. <br /> ga, 9b.U.S DOT Description(including Proper S'ripping Name,Hazard Class,ID Number, 10 Containers 11 Total 12 Unit <br /> HM and Packing Group(if any)) 13 Wastr .,.; <br /> Na Type Quantity WlNal <br /> CC <br /> 1 t10td-F1('IBAhIA—,AI�(1(}11�:1PJASI *,r111f1 AH!SO713Fhf1': (1, r Ik111 'eml P <br /> a <br /> 2 2 <br /> L <br /> c7 <br /> 4 <br /> 14 Special Handling Instructions and Additional Information <br /> 140)1-111.L11 I I iU511lfV1i,i AB ,UIZi51I16,Ull t IVter: {T{ <br /> FR4ciir�F:tk1t:Y(,LJrdl'r1f;i i if <br /> 15. GENERATOR'WOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are dassifed packaged <br /> marked and labeledlplacarded.and are in all respects in proper condition for transport according to applicable in mational and national governmental regulations.If expert shrpment and I am Pte Primary <br /> Exporter,I certify that the contents of Ibis consignment conform to the terms of the attached EPAAcknaMedgmeM of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)N(b)(ill am a small quantity generator)is true <br /> Genemlor'sl0fl/eror's PrintedlTyped Name Signature Month Day Year <br /> I A <br /> x 16.International Shipments <br /> ❑Import to U.S. ❑Export from U S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU <br /> 17 TrunsporterAdknowledgment of Receipt of Materials <br /> GTransporter`I PPnriteyped�Nama �,r �% /�_ Signature ...... M7- <br /> Ca <br /> pay Year <br /> CL !i'f �•� f' :'!�rJi:f�JYl1. -� � r� /_��ir/�f"' IJ J ,rfA <br /> Tran sp e 2 Printe yped Name J (/ / f C--- Signature MSRih ►Day r Yedr <br /> r f .. ' <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Space El <br /> OuanGty El Type ❑Residue 1:1 Partial Rejection El Full Rejection <br /> Man.fesi Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone <br /> w 18c.Signature of Altemale Faciity(or Generator) Month 7Day Year <br /> a <br /> z <br /> 19-Hazardous Waste Report Management Method Codes(i.e codes for hazardous waste treatment,disposal and recyd3ng systems) <br /> 0 1. z 3 Notice: State of California requires <br /> generator to photocopy and mail to <br /> 11 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncled m ftem 18a DTSC with 30 days: <br /> Printed[TypedName Signature P,0 Box 400 <br /> 1 Sacramento, CA 95812-0400 <br /> EPA Farm 8700-22(Rev 12.17) Previous editions are obsolete GENERATOR'S INITIAL COPY <br />