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Please print or type. RIP <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUSi.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest hacking Number <br /> WASTE MANIFEST 1113 001791865 VES <br /> S.Generator's Name and Mailing A dress 0 n 6 2 Gu etat rsite ddress(€f different than mailing address) <br /> YULENNA 43ALVAN <br /> *W IBX 6A3Qi <br /> "S now WAT <br /> se .711`1 <br /> 6.Transporter 1 Company Na U.S.EPA IU Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> he <br /> 8,Designated Facility Name and Sfte Address U.S.EPAID Number <br /> LILCI <br /> Facitily+a Phone: CA 94101 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) Na. Type Quantity wt-tvOl. <br /> 1. 0i3NPAROW COWNIEBM 331 <br /> OR UO3WM dAg,12 <br /> T 1 P <br /> w X 2. URL431,WAM PAW VXATW MiTMr 4 3,E,IQ Dw <br /> ch <br /> 3 D F 400 P 331 <br /> 3' NUNJERARVA11DIXEWArMYnXZ%(8®[XYUM 141 <br /> SULEONAM WAnM <br /> 1 17 F 160 P <br /> 4. NON-SIE"BAHMWWMWAMLiQ=a+4=141M. 331 <br /> CEO 4 D F 1 do P <br /> 14.Special Handling Instructions and Additional Information ER 84n1 K 000mud W YAM + �i <br /> qpoo F=Wm d flintw 6dllotlyl a b&& - I �W.'f14 0 A: <br /> �490 A 911445�4t X W'.1Q5 A=M 119 57D•12A6 4)W15?9.AWACf1L99 <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,packaged, <br /> marked and Iabeledfplacarded,and are In ag 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 M consignment conform to the terms of the attached EPAAcknoMedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(01 am a large quantity generator}or(b)(ill am a small quantity generator)is true. <br /> Gene ator'sl0fferor's PrinledlTyped NameSigna e -� Month Day Year <br /> 6� <br /> F 16.International Shipments ❑Impart to U.S. <br /> ❑Export from U.S, Port of entrylexll: <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> fK 17.TransporterAcImewledgment of Receipt of Materials <br /> Trans r 1 Pdntod Typed Name Signature Month Day Year <br /> CL <br /> C-em 1-1O� Zt <br /> U) Transporter 2 PrintedTfyped Name Signature Month Day Year <br /> 416 vyl-r L2-,Lr <br /> 18.Discrepancy <br /> 18a.Discrepancy Indlcatlon Space tib' ❑T ❑Residue ❑Full Ra <br /> ❑ Quantity ype El Rejection Jectlon <br /> Manifest Reference Number: <br /> 111b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W FacilitysPhare: <br /> LU 18c.Signature of Alternate Fardilly(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes fon hazardous waste treatment,disposal,and recyding systems) <br /> 1. /fry 2. 4. <br /> 20.0esignated Facility Owner or Operelor:Certification of race€pt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name J f r, r� Signature Month Day Ye f <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. �/� DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />