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Form Approved. OMB No. 2050-0039 . .
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<br />UNIFORM HAZARDOUS
<br />VVASTE MANIFEST
<br />1. Generator ID Number
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<br />2. Page 1 of
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<br />3. Emergency Response Phone
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<br />4. Manifest Tracking Number
<br />019703741 JJK
<br />Generators Name and Mailing Address r ...Ae..< 1;_,.; i,, f_ Generator's Site Address (if different than mailing address)
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<br />Generators Phone SiCyr-. '6 Z-q C.1.2)06 C rib If 4-,y. CA 5 sz 1..'
<br />Transporter 1 Company Name U.S._
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<br />EPA ID Number -
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<br />Tra porter 2 Company Name U.S. EPA ID Number
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<br />Designated Facility Ndme and Site Address C ,-., -s i..... , 1. ,-_, U.S. EPA ID Number
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<br />Facility's Phone `
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<br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11. Total 12. Unit 13. Waste Codes
<br />Frm and Packing Group (if any)) No. Type Quantity WtNol.
<br />1. NA, 2 c27 Vki:Z..44-30 1„,t)(.0kc Sos1;1 , ,./11- 0 • 5.- ‘ IS I C001 K
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<br />14 Special Handling Instructions and Additional Information
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<br />15 GENERATOR'S/OFFEROR'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,
<br />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
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (ill am a large quantity generator) or (b) (if mall quantity generator) is true.
<br />Generators/Offerors Printed/Typed Namee, i Signal Month Day Year
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<br />r-Eli 16. International Shipments Export from U.S. Port of entry/exit: Import to U.S.
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />O 17. Transporter Acknowledgment of Receipt of Materials fiRANSPORTE Trworteri1 Fi' inted/Typed Na e Signa il Month Day Year
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<br />Trans 2 Printed/Typed Name ' A
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<br />Signature
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<br />Month Day Year
<br />I 05 ioea) I 4------- DESIGNATED FACILITY " 18. Discrepancy
<br />Discrepancy Indication Space 0 Quantity Type Residue Partial Rejection Full Rejection
<br />Manifest Reference Number
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone:
<br />Signature of Alternate Facility (or Generator) Month Day Year
<br />19. Hazardsrus Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />20. Designated Facility ow eror Operator: Certifica on of receipt of hazardousinaterials covered by the manifest except as ncted in Item 18a
<br />Printed/Typed Name
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<br />Signature Month Year
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<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. S e-
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