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800 E. Pescadero Ave Record ID# PR0514340 <br /> 11/20/2020 Program: HW <br /> Photo 22: The following uniform hazardous waste manifest (006425887SKS) with no signed designated facility copy. <br /> tie n�nl or lupe.(Fryrm dengned for use oq stile f12-pinch 11'ed.GMB No-205MG39 <br /> uN1FORM H )lypewmer) <br /> WASTeM EST US t,Gena+alarlo Number Form Approved.OMB N.20500039 'C+q ��� <br /> s cene.al„rs Name and Mallen a - 1 Page+or aameyenn a,sPa„se Priono e-Mmiher aracFlnN xemae[ J{� <br /> 9 bare%% 06425887 SKS <br /> • Generatys Stle Atltlress l,f daAerent man metleg addmsel <br /> Generalola PhUna'. L!, <br /> fi Transporter t CoiPPanY warns ._ . <br /> �Transppner2 LOm fG$.EPAIG NumLgr <br /> Parry ryame <br /> a❑%si na U.S.EPA1U Numper <br /> 9 led Faallly Name anq Site gdarasa <br /> SAFETY—ISLEF:k �Y5'i fflo� 1Nf U.s.Eon to Number <br /> FOOT' a1aTH s7REfT <br /> Cl <br /> Facility's Phone: <br /> 9a. us IiDesuipaon iinpydigg Pieper Shipping Name,Hazard ass. Number. 10.Gonlamer5 \Na%la Code,¢ <br /> HM and Packing Group pfanYll IUIt.Thal 12.umt <br /> a 1- <br /> N. Type O—In' WWI 13.Wane CMes <br /> Q <br /> � 1 <br /> w 1 <br /> w � <br /> 3 <br /> :4.Special Handling Insrn+clions antl Adtlieonal Iri(wmeaon <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION', hereby declare ula3 the contems of this cor�signmanl are fully antl acCuralei descnhed alwveb the oma <br /> Y Y Proper sleppi name,and are rles,rel packaged, N <br /> marred and labeled/placarded,and are in all resre=in Pmper condition For 4anspon—ording W applicable inlemational and national governmental regulations.If exporl ftmenl and I am the Primary <br /> Evoner,I certify that the oono a of Ihis consignmarl Cant—m the[arms of the attached EPAAcknowledgmen!o!ConsenL <br /> I cendy that the waspsminimization slalement identified In 40 CFR 262.2?(a)(it I am a large yueni generaloq ar(h}(ill am a small quantity geeeremq Is true. say Year <br /> Generavpewolffo,&f Pnntecllypoa Name❑ Sgnature <br /> `9 MjrAh Day Year <br /> J 16.International Shipments +-- <br /> z import to U.S- ❑Esporl morn U.S. Port of entryient <br /> Transporter signature(for eeporis only): Date leaving U.S., <br /> tzw.l 1 I.TranspoderAck Maogment of Receipl of Materials Year <br /> W T2Psponar lr Polledlfyped Name Signature <br /> a Month Day Year <br /> � Transponer2 Pnnledfiypad Name Year <br /> Signature <br /> Month Day Year <br /> S 18,Discrepancy <br /> 1 nn <br /> fEa.Discrepancyicatlon indSpace ❑OUentily ElType Residue ❑Partial Faisal ❑Full Relectlen n <br /> Msmfe50 RelererNe Number: <br /> Faality(or GeneralorJ U S.EPR ID NumberUI <br /> 1,16thl,Afirmarm <br /> aeilVs Phone: Year <br /> w till.Signature of Alternate Facility for General <br /> 4 Month pay Year <br /> Z <br /> N19 Hazardous Waste Report Management Method Codes(re.,codes for hazardous waste freatdllent,disposal,and recycling systems) <br /> w t 2. <br /> � 9. 4. <br /> r Al Designated Facdlly Owner or Operator Conific2hpn of it ipt of hazeNuue mal Covered by tho manifest except as ni Irl item IBa 'ar <br /> Wa <br /> P-e Typed Name Signal Month Day Year <br /> Py <br /> EPA Form 8700-22(Rev.3-05)Previous edifions are obsolete. GENERATOR'S 11NIMAL COPY <br /> JASON GAITAN, REHS Page 22 of 34 <br />