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Please print or tYOf � l�lll�� 1� Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t If3.Emergency Response Phone 4.Manifest Tracking Number C <br /> WASTE MANIFEST 0 01795524 VES <br /> 5.Generator's Name and Melling Address , EVAN Generator's Site Address(ti different than mailing address) <br /> FED EXCIROLM SAM <br /> 5655 BDOOD WAY <br /> Gen�era�,95377 7217 <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> D 0 9 0 6 3 I <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> MP WMO)DAENTAL MVM C A T 0. 0 0 6 2 4 2 4 <br /> 8,Designated Fadllty Name and Vle Address U.S.EPA ID Number <br /> VBWA ES TBCHWAL <br /> LLC, <br /> 1125 E0949"S7RJMT <br /> Facill s Phone: i XXMMCINCr CA 9WI C A T d 8 4 <br /> ga, gb,U,S,DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Conlai,is 11,Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt VQI. <br /> X 1. EM263,WA8'!'8 PAINT IMATELD MATI111A4 3,9,RQ D001 <br /> �) <br /> 1 DM a00 F' 333 <br /> 2MCRA HAZ�l1EDQE�WAA'I8 Ltd.(L+�'�C PAW1. 331 <br /> 2 D F 600 P <br /> 3. ��BATaRDD1.1S WAM SM W "49MW <br /> 3 D F 40 P <br /> 4. <br /> 14.Special Handling Instructions and Additional Information + <br /> sawyRb mWWA III r, w) �s� 6�Z3�°�� baAalf. -� 1 �# 12BW�7f490A <br /> 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,padkaged, <br /> marked and labeledfpiacarded,and are in all respects In propercondition for transport a000rding to applicable inlematlonaland 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 ceftily that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(di am a small quantity generator)is true. <br /> GeneraloeslOfforoeg Printab7yped Name 1/ / Signature Month Day Year <br /> J .Lfltemellenal Shipments low to U.S. <br /> ❑Export from U.S. PoA of entrylexit: <br /> Transporter signature(for exports only): Date Leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> Transporter 1 Pdnledlryped Name Sig Month Day Year <br /> aQ, KFVW�Tto 1 111 $12 1 <br /> Transporter 2 Pdnledflyped Name Signature Month Day Year <br /> t— Z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Resk€ue <br /> ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> uQ. Fecilitys Phone: <br /> qW 18c.Signature of Altemate Fading(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste <br /> /Report Management Method Codes(Le.,codes for hazardous waste Ireatmeni,disposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Facility Owner or opetalor:Certification of receipt of hazardous materials covered by the manifest except as rKted inItem18a J <br /> PrtniYear <br /> aerne Signature _hz"!q "r/ Month Day 2 R1 <br /> f/�i/`,f I 3 <br /> EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />