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1 Please print or type. Form Approved.OMB No.2050-0039 1.Generator,ID Number 2.Page 1 of 3•Eme gency Response Phone 4..Manifest Tracking Number UNIFORM HAZARDOUS _ ani kin �j w WASTE MANIFEST C - �v�J't~J 1"� `�� 'i�" - r roc o-r c1,y "� 2-0, J 4.J 5 5 3 3. J J K 5.Generator's N me and Mailing Addrgs G66er5or's Site Address(if different than mailing address) Generator's Phone: _ 6.Transporter 1 Company Name U•S.EPA ID Number 1AJV'')0S EP 'IR.ONME)*V7 J-SERAX-E`11111C. >rACFiJ�C0355a 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number F?AR�IOS Er�lIrirrtClfUPbil�[!lilk3_SERVICESli',1t.�• Gr+.L'fi.1A%f�'�r�•',-'k.',, '•. 11515 SOUTH RIFER K0. WEST SACRAA9ENTCi,CA 95591 Facility's Phohe:1316.31 1-5747 ya 91b.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. I r- .t'4lSl - s 4:; _ , -1a 123 z 2. w c� 3. r' 4. 14.Special Handling Instructions and Additional Information 9611. E-RG 3171 H.ARti LERS TO SE TRAINED AND USE A30PROVED PPE. E..R,. coNT6g:ewfr-;R: rv,,.os EN'VlROI&IENTlAL SE;tLNC 3 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 EPAAcknowledgment of Consent. I certify that the waste"minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or fib),if I am a small quantity generator)is true, Generators/Offerors Printed/Typed Name Signature/ / Month Day Year, 16.rhternational Shipments• ❑ F- ❑Import to U.S. Export from U.S. Port of entry/exit: K- Transporter signature(far exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of MaterialsLLJ r t Tr a orter 1 PrintedlTyped N�rna'r Signatuie' i Molt Day Year OCL (16, L .:, 4 ii�l Ir Z Transporter 2 Printed/Tyd Name Signature Month Day Year r- 18.Discrepancy,. 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U W Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report.Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardyus materials covered by the manifest except as nce¢in Item JBa Printed/TypgdName,,, /' Signature ' r+" l .��' Month }Day�p Year EPA Farm 8„00-22(Rev.12-17) Previous editions'are obsolete. DESIGNATED FACILITY COPY IF vnl I RFr.FIvFn THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST.ACT.SEE INSTRUCTIONS ON REVERSE SIDE.