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Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2 pa <br /> UNIFORM HAZARDOUS ge 1 of 3.Emergency Response PhoneManliest Tracking Number <br /> WASTE MANIFEST C X392 '1 4. 0204 3275 JJK <br /> 5.Generator s Name and Mailing Address <br /> r� CO.4 i.IG Generatods Site Address(if different than malting address) <br /> !#511.1f11i:�RY <br /> 178D MUST RIAL Cir, <br /> STM-MN,CA 9M <br /> Generator's Phone: 234-16r <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 1"a$"ge W. Lamy.h c'. C� 7+315 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> U.S.EPA ID Number <br /> 1620 F—_1WUWAQLw!-it CAL0002W= <br /> ! 1*RSFtC—LO.CA 93W7 <br /> Facility's Phone:4%1 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(1f any)) 13.Waste Codes <br /> No. Type Quanuty Wt.1Vol. <br /> 1. f,f•;?.t4`. RCRk l�Zpmwuli ','`.'`_`i' SOLID (011Y ablo bent C4t`v1 P 3 <br /> O r, <br /> Z 2. <br /> IW <br /> V <br /> 3. <br /> 4. <br /> 14.SSppe/edall H�a]ERG 0 rrLdlyyinn-�gg Instructions and Additional Information <br /> ES <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: [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 international and national govemmental 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifl am a small quantity generator)is true. <br /> Generators Offerors.PpnfedfTyped Nams. Signature Mogth Day Year <br /> 16 International Shipments w. <br /> _ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> a' 17 Transporter-Acknowledgment of Receipt of Matenals r <br /> LLI T\ <br /> pTra Pri ed Name Signature i� 1 <br /> Month„ Day Ye . <br /> CL _ <br /> zTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ <br /> TYpe ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifost Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone. I <br /> Fc.Sign <br /> 18ature ofAltemate Facility(or Generator) Month Day Year <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. 2 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />