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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A R 0 0 0 2 8 5 9 3 2 1 1-3w019 7 5 9 5 3 3 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) CCSF Mpaltrnlnt o1 Pub6C HeaM TTf T FWW 1390 Molri*St STE 210 9000 W.VaMlk Rd San F"WKbW CA 94102 TWV CA 96377 Generator's Phone: d 4 A 9 A 6.J1PI v64ary2rr w. td,5.W IR"b"b 0 2 1 7 5 1 3 J.Transporter 2 Company Name U S EPA ID Number 8 1qj1 €1erWnd Site Address U.S.EPA ID Number 180 W.MOW&AMMM Bbffl*Abn CA 92316 Faclliry'sPhone: 909 421-2012 CAD 9 8 2 4 4 4 4 8 1 9a, 9b.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, 0 1 /3 221 W 2. 3 4. 14.Special Handling Instructions and Additional Information 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 nal I governmental regulations.If export shipment and I am the Primary Exporter,1 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(b)(ifpp m a All quantity generator)is true. Generator siOfferors Prinled/Type l Name ~ Signature Month D y Year FF 3 1 16.International Shipments F— LJ Import to U.S. ❑Export from U.S. Port of enirylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter tPr Na Signature Month Day Y ar Transporter 2 Prin E yped Name Signature Month Day Ye rr 18.Discrepancy 18a Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection ManlfestReference Number 18b Alternate Facility(or Generates) U.S.EPA ID Number J t..) I. Facility's Phone: W 18c,Signature of Alternate Facility(or Generator) Month Day Year a Z Fn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1 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 Printed(Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM