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Please print Or type Form At) roved. OME No. 2050-0039 4 SIFALFRATOR . . UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number. '-':' Ai 64.•... VES 5. Generator's Name and Mailir g Address Generator's Site Address (if different than mailing address' -YUAN:If/1 tiAlf-VAN :'.0 I:2', : tZ1 '5 MOT" 10.7 Generator's Phone. I 6. Transporter 1 Company Name U.S. EPA ID Number ,...:.11:, 9012,..-11.0KIs I 7 7 ' 3 r sporter 2 Company Name U.S. EPA ID Nisnber : Iffr4473 I - S. Designated Facility Name and Site Address U.S. EPA ID Number ref :11,FICAL. cl*.gliTti'7.- r....i. .t. 1. MS FIFITRIEY HI7 reY : ' Hittite: CA. V - Facility's Phone: .-.. iii:, io44 1...rw. Ma !. ga 9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class. ID Number, 1:,) Coitane,-s 11. Total 12. Unit 13 Waste Codes NIA and Packing Group (if any)) Type Quantity Wt/Vol. X 1. 1.2112,51, V SrE PA3T' IMATFD 1,14.11MAI, 34 (—a.- cmitosrvii,mr,m, 41-Infc, Mgr( Ater.% r .6.. OtReTTEOPI.0 Arry}.. it, n .: _ 14 Special Handling Instructions and Additanat Information Mt Atorvioe W.--xiseeiled by Vhar d ,•;,- 0?-4ii 4..4014 l:r ,i.,!.1.14 ,i e.;Af:': ': 'liteAS1, :,-iti, ; ,.. : -,:, „., gdol at inhatentia addidovel staumrtere al. itt)-r'if. beghtt * ..1: ,-. %TAU. V)4 2A.' trr-00045."11 ii: rzialluit4it..g.i AAAPTANTNOCl2 .11 '7,071324 Airrft• .: ,c29 15 GENERATOR'S/OFFERORS 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 labeled! placarded. and are in all respects in proper condition for transport according to appicable 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 jam a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year t N I I I I _I . 16 International Shipments Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only) Date leaving U.S.: TRANSPORTER I 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name , Sicnature Month Day Year I III Transporter 2 Printed/Typed Name Signature ' ' Month Day Year I I I I DESIGNATED FACILITY 18. Discrepancy 18a Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejector, Manifest Reference Number: 18b Alternate Facility (or Generator) U S. EPA ID Number Facility's Phone: I 18c. Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, dispose., and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ndad in Item 18a Pnnted/Typed Name Signature Month Day Year I I I I ----- .---,- .......... ........... EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.