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Please print or tgpe.,(Form designed for use on elite(12-pitch)typewriter.) + Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST +v 9 6 1 209-667-8657 1001738275 FLE 5.Generator's Name and Mailing AddressGenerators Site Address(if different than mailing address) f{coy t� � ��ys � �( ai c,npl-r'QI P,(Io ^1 W; c A 0 �S a Generator's Phone: r - . �,9•^� �f T N `ter 6.Transporter i Com any Name U.S.EPA ID Number AMERICA VALLEY WASTE CIL CAL000821878 7.Transporter 2 Company Name U.S.EPA ID Number 5.DWIFRIMM"010TRANSFER U.S.EPA ID Number $300 CLAUS ROAD CRLOOO1 10916 RIMBANK,CA M367 209-86"181 Facility's Phone: ga 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./Vol. 1. 1 1 221 I 1U3E[?CILYiNATFR) 0 0 1 T T ' w Z 2. W CDr.... 3_ 4. 14.Special HandlinftID"Scl Additional Information 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratery described aoove 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 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 quantity generator)is true. Generator's/Offerors Printed/Typed Name Signature Month Day Year 11' 4 5 16.International Shipments z ❑Import to U.S. ❑Export from U.S. Port of eniryle>at: ------- Transporter ___Trans orter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials t2 Transporter 1 Printed/Typed Name Signature Month ay ear a QTransporter 2 PrintedrTyped Name signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Q LL Facilitys Phone: G 18c.Signature of Alternate Facility(or Generator) Month Day "ear Q Z — y19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. Y0-f 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name t S f Month Day Y,)ar. EPA Form 8700-22(Rt 5) Previous editions are obsolete. - DESIGNATED FACILITY TO GENERPTOR