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Please print or type. Form Approved. OMB No. 2050.0039 It UNIFORM HAZARDOUS :[. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number WASTE MANIFESTF 4 I I JJ K = , 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) t : . , . , Generator's Phone: ! 4 6. Transporter 1 Company Name U .S. EPA ID Number 3 � h i1 . 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number !4 0, , rp Facility's Phone:i '- ga, 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. 1 . 2, L G7wA 3. 4. 14. Special Handling Instructions and Additional Information 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 international 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) (ifl am a small quantity generator) is true. Generator's(Offerors Printed/Typed Name Signature Month Day Year 16, International Shipments ❑ import to U.S. ❑ Export from U.S. Port of entrylexit: Transporter signature (for exports only): Date leaving U.S.: � 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 2E Transporter 2 Printedfryped Name Signature Month Day Year F� 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Typej j ❑ Residue El Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number RECEIVED AUG 1 �, �0 0 Un Facility's Phone: Uj 18c. Signature of Alternate Facility (or Generator) Month I Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1 2 3 Notice : State of California requires generator to photocopy and mail to 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 d ayS : Printedrryped Name Signature P . 0 Box 400 Sacramento, CA 95812-0400 EPA Form 8700-22 (Rev. 12- 17) Previous editions are obsolete. GENERATOR'S INITIAL COPY