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Please print or type. - Form Approved. ONE No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator lD Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trucking Number ` ,C WASTE MANIFEST - L 5+ L, - VES 5. Generator's Name and Mailing Address AuDIIII Generators Site Address ('rf different than mailing address) . . .i ., . . _ �Wt IN JrA&CoAATHL3L DR STE IOD 4L P.)U lr'y i, ,% OST^K 4911 -.RAC`lCA III Generators Phone: Ilat4 ,11fil 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number LL. I PNA W. MST SIMI Facility's Phone: - ' 9am 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 WWoI. 'F' d. _ O z 2. W fJ 3. 4. 14. Special Handling instructions and Additional Information all stiiorrry nn WkW mapullron w " iS sYbrreWC wwwnurw fwar if 6Wil -E i y w: I61 A:AdOI FLrRI.:-'t 21 W.414914 A:A7A1-A911YL•8RSfN9 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 Iabeledlplacarded, 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 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneratoeslOfferors Printed(Typed Name Signature Month Day Year x 16. International Shipments - r ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit ? Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAcknowledgment of Receipt of Materials _ Transported PrintedRyped Name Signature Month Day Year O wz Transporter2PMW/Typed Name Signature - Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ QuantityType ❑ ❑ 1 ❑ Full Rejection T e Residue Partial Rejection Manifest Reference Number: 18b. Animate Facility (or Generator) U.S. EPA ID Number J U LL Facility's Phone: w 18c. Signature ofAltemate Facility (or Generator) Month Day Year C z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatrent, disposal, and recycling systems) 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY