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Please print or type. Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1•Generator ID Number 2-Paye 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST s i+ 021110823 JJ K 5.Generator's Name and Mailing Address Qeneretor's Site Address(If different than mailing address) i.. ivlC NE 4NU Ry, - . . - . '-,A 95337 Generator's Phone: 6.Transporter 1 Company Name y� U.S.EPA ID Number 7.Transporter 2 Company Name y ,• .4r U.S.EPA ID Number S.Designated Facdily Name and Site Address � U.S.EPA ID Number Facie Phone: 939b.U.S.DOT Description(Including Proper Shipping Name,Hazard Gass,ID Number, 10,Containers 11.Total 12.Unit HM and Packing Group¢ I.f any)) No. Type Quantity VAIVo13.Waste Codes 1'• ice u.r Z 2- Lr 3- 4- 14.Special Handling Instructions and Acct banal Information 71 CACy ut'y 5 e; ?5. 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, ma*ed and labeted7placarft and are in all respects In proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 46 GFR 262-27{�(9 I am a large quantity generator)or(b)(if I am a small quantity generator)is We, ypg S nature p Month Day Year Generator s70ftero2s PrintedlT d Name �i d rA t] f r 1 d� Y 4 1 1lti rte(' �:3 Vr �. 'u 1 16. :t2macr. l5h;pirents i= El Import to U.S. ❑Export from U.S. Port of entryfexit Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transppxter 1 ntedr-yped Name Signature Month Day Year z Transportaf 2 PKrKedrFyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Qtcantily ❑Type - ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, F 18b.Alternate Faciily(or Generator) U.S.EPA 1D Number J_ LJ sat Fadlity's Phone: LO 18c.5lgnature of Alternate Facility(or Generator) Month Day Year a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator-Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a Prmtedlryped Name gnature. 1� Month pad.. Year EPA Farm 8700.22(Rev.12-17) Previous editions are obsolete. 51GNATEQ FACILiTYTG GENERATOR