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Please print or type. Form des ed for use on elite(12-pith)typewriter.) Form Approved.OMB No.20SM039 UNIFORM HAZARDOUS 1.Generator ID N mbar 2.Page 1 of 3.Emergency Response Phorm 4 ManNaethack! Numher WASTE MANIFEST 121 f pug: 91;s-6/1 005503,44 FLE 5, enerator's Name and Mailing Address Generator's She moress J11 Merent than mat ng address) �tt►rat#tgrr r'A ni5 1 '•ja kton, CA 915710 Generator's Phone: :µ��0)9 5-64 a5 ransporter 1 mpany Name U.S.EPA ID Number 7.Tranaporfar 2 Coaipp4ny Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number l 17.401A°rno I(,Rrtlaor i F�R r, -A 90222 � 637- lor go. 91h.U.S.POT De9alWn(Including Propei Shipping Name,HmM Class,ID Number, 10,Contalners 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No, Type Quantity M.Ml. UN (24mwilnt Ii1,3 1'3yri 2- R7 3. 1 4, 14.Special Handling lnaVVt*, ns and Add<tional Information r R 1 Zt9 '04�AP PIR1 Pf3IATE BE' ,! 219 i J, CLOTHING. 15. DENERATOR'S/OFFERGR'S CERTIFICATI : I hereby dedare that the Contents of this consignment are fully and accurately described above by the proper shipping came,and are classified,packaged, marked and labeled/placarded,and are ill all respects In proper condition for transport according 10 applicable intemational and national govemmental regulatlons,If export shlpmert and 1 am the Primary Exporter,I Certify that the contents of this curisigorytent Con1tDrm to the tonna of the attached EPAAdmo%4edgmer9 of Consent. I certify that the waste minimlaMlon statement Identified in 40 CFR 262.27(8)(If I am a large quanifty generator)oe(b)(H I am a small quantity generate)Ig true. nere n Signature on ay Year Iii.International Shipments " ❑Imp( to U.S. ❑Export from U.S. Pert til tallhyhtdt: Trans iter S nature fir exports only)- Date"VIM U.S.: 17.Transporter ACknowledgrnent of Receipt of Ma rials ransport&1 NritodfTyped Name Month Day ear 4 Transporter 2 PrtrtaTypW Name Signature month ay Year 18.Discrepancy 188 DlscrepetlCy Indication Space ❑ 7tity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 180,Alternate Facility(or Generstor) U.S.EPA ID Number Fecdi a Phone: 18 c,Signature ofAllemats Facility(of Generator) Mordh Day Year 19 Hazardous Waste Report Management M0oj Codes(I.e„Codes for hazardous waste treatment,cisposel,and recycling systems) 1. 2. 3. 4. 1 20.Designated Facility Owner or Operator:CC 4f feCElpt o1 hazardous motorists covered by the manlfeat except as noted In Item 18a Pdnted(lyped Name Ign8llNe Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY