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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifes <br /> t Tracking Number Cc <br /> WASTE MANIFEST ;: r r 1 r'f 71 is t '.fsr<^ i.d1 9 4 VES <br /> - <br /> 5.Generator's Name and Mailing Address BARRY 3I.E'Ii3. Geneiator's Site Address(ff different than mailing address) <br /> 6300 LINDEERGH STREET <br /> S°l'OCKTtjX CA. Q5206 <br /> Generator's Phone: "R C""%I I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> UP EIMII•iC3NIbIxs11M, C A T 0 t j 6 2 41 4 <br /> 8.Designated Facility Name and Site Address 55 rp ,,��aap��3 4pCXx yp U.S.EPA ID Number <br /> b�tt�5..1.`r'i i..'i 14A-3iY 54.Fki�:7 L,�e�s}�����e <br /> r.L.C. <br /> i 1.5 13E`t�iSLEI''STREK <br /> -Y}yq�i�Irf, �.�. ���f} <br /> Facility's Phone: y,ii ".s iii i o A T I; g U ll ; 4 at ',r 9 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(if any)) <br /> HM No. Type Quantity Wt.Nol. 13.Waste Codes <br /> of �'C1'R6#.IU di A l„IMIP9tId�-3Z]z'.,, 9, 1I1 <br /> I C E s fa 141 <br /> z 2. <br /> L <br /> 69 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information ER Femi=e C.or-tfacted,b7 ESTE 1- � � � T <br /> ra asp�g _t z� r►5-� - 4._�r`�.?d R'��i�5'>�+i���liri e3�t'b3"C'[r$3�#T"s <br /> 4�._r 0ar'it�7`O L,iuida, ,a,aqt otter t,; add or subs titate a�€+fidondl 2raxts��: <br /> ,;+.l.T.�F.070j 2@YL 10 9 <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 international and 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 generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeror's Printed[Typed Name *nature Month Day Year <br /> r'1 c r 1 ✓ -7 <br /> 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> UA <br /> Transporter 1 Printed/Typed Name Signature -` Month Day Year <br /> U) <br /> Transporter 2 Printedfryped Name" Signature. Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> LO 18c.-Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> V519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI G 1. 2. 3. 4. <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. GENERATOR'S INITIAL COPY <br />