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Please print or type. Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST `; r. _ 3* 010 _ =' "--; 022830945 5,Generator's Name aid•Mailing Address Generatat's Site Address(if different than mailing address) _;amnif`Y1ae# C.e"1 '�-`'1 ita,,.. 4 :t,rLa i..i't 1'1. Generator's Phone' O l_ 6.Transporter 1 Company Name U.S.EPA ID Number +rlc. - 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number j 50 1-,PIC'o'9:iYid CA W.122 Facility's Phone: i` 1r- p. - - _ - ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No- Type Quantity Wt.Nol. Of 11rt?i'!LiD,V t-.�-ic#tt ri3b#v �r'1#ts5::f-u!s#«,€i,U.�. /� 000 roo z 2. w 3. 4. 14.Special Handling Instructions and Additional Information _ ;f f-i G'#''1.._e`:• _. i"Y.=1.__ ._. J' _0i 3�_:_:. '.3?r't:� i ('r«#?f�l�a'f"t.? 'reri,��P�__)`t :!_;i� ❑.,>:• a1110 i_�`.,o-• .a 3D =it:'[0D 2 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,ard are classified,packaged, marked and labeled/placarded,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 EPA Acknowledgment 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)(if I am a small ggantity generator)is true- Si Pdnted/Typed ame Si nature Month Day Year J 16,International Shipments Import to U.S. ❑Export from U.S. Port of entry/exit: 1:1p ? Transporter signature(for exports only): Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials w Transporter 1 Printed(Typed Name Signature f/ Month 12 QZ Transporter 2 Printed/Typed Name Signature Month Day Year fY 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ElResidue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V u- Facility's Phone: C3 18c.Signature of Altemate Facility(or Generator) Month Day Year Q Z CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) a 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