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Please print or type. <br />IIIForm Approved. OMB No. 2050-0039 <br />EPA Form 61UU-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number I <br />WASTE MANIFEST <br />VES <br />1001796184 VES <br />Generator's Site Address (if different than mailing address) <br />5. Generators Name and Mailing Address ADREAK&UNIOCK1141=11 <br />100 YAt"11>�RDB <br />FWCAffi'UXURCM'700 <br />1AWN 918 <br />ACT�s�P'.hA 44376-'201 �iUCV. CA ' <br />G <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />VEIMMIN TTEICEtWCALVOLMOM 1IR J D 0 R O 6 3 1 3 6 9 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />VBKXIA HB TBCHNWAL SO LTITON , <br />LLC. <br />1133 EE21ftBY 9TRWr <br />Facility's Phone: CA OWI C A T 0 6 0 0 1 4 0 7 9 <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />Wt.Nol. <br />PXWRMA EREARDIM WPM SO= OW FM <br />3n <br />1 <br />C F <br />11 <br />P <br />z <br />z. <br />W <br />:9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information IR VWVW by VMM + Q4011114ti by 49A11:111 <br />o * in t�poebi b SK of nbfftbb dd�ed trai!)paefl� in jji)w�dat4 b&& + 1) W i A: <br />M <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, and 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 EPA Acknowledgment of Consent. <br />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 quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signature Month Day Year <br />r L v v <br />F <br />16. Intern nal Shipm <br />❑ Import to U.S. ❑ Export from U.S. P of entry/exit: <br />? <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedlTyped Name Signature r�� Month Day Year <br />a <br />XvL M i3V-4-C l <br />5E <br />Transporter 2 PrintedfTyped Name Signahe Month AQ Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quanti ty 1:1 Type El Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />2 <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. 14 14/ <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noed in Item 18a <br />m <br />Print hyped NaSignature Month Day Year <br />EPA Form 61UU-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />