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Please print or type. SOMM11IIIQIQ Faint ved.OMB No.2050-0439 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Paga 1 of S.Emergency Response Phone 4. sn st c ng umber <br /> WASTE MANIFEST 001794721 VES <br /> 5,Genaraloes Name and Melling Address Y1111211A GaVAN Generators Site Address(H different than mailing address) <br /> FWRXC RIIM SAME <br /> SASS 9=WAY <br /> j�gWsCAPho7M7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> VBOM 23 SAL 9OLUMM IN s D 0 8 0 6 3 1 3 6 9 <br /> T.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facilily Name and Site Address U.S.EPA ID Number <br /> VE1110MISMORMA1. , <br /> r_i_n <br /> 1193 HENE"S'IIM <br /> Rxzwmc�CA <br /> Fadli s Phone: 94801 C A 7' 0 8 0 0 1 4 0 7 9 <br /> ga. 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1t,Total 12.UnH 13.Waste Cedes <br /> HM and Pecking Group(If any)) No. Type Quantity WtNol. <br /> O x 1. E �. nawrA1Im0aLn%w= 331 <br /> 3 C Y 27 P <br /> Uj 2. NMRM WAMUS WAS'YB LPM(LAIn PAID 331 <br /> 1 DF 213 P <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Infoanation 111th 17 V= + Commwk*d y CRS <br /> m Y3tW lerpallet <br /> loom at S III ttI etltltliori a 64WL -F 1 1u412t3 X71493 A <br /> w� A)W:71S211 A:P'PAWISM <br /> 15. GENERATOR'S/0"EROR'S CERTIFICATION: l 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 labeledlplacarded,and are In all respects In properoondilion for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cer*that the contents of this consignment conlonn to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I cer*that the waste minimization statement identified In 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(OI am a small quantlly generator)is true. <br /> Generatoesl0lforoes Pdnteffyped Name Signature Month Day Veer <br /> YUEJUACIAL 0 1 12 <br /> .1 16,international Shipments <br /> ❑Import to U.S. El upon horn U. . Part of entiylexit <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> UA <br /> 17.TransporlerAdcrwMedgmentofRecelptofMaterials <br /> 12 Transporter IPrInted/TypedName Signature Month Day Year <br /> a BA�IY mm 0 1 12 7 0 1 <br /> ZTransporter 2 Ptinlekllfyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑PO.1 Re)ectioro ❑Full Refection <br /> Manifest Reference Number: <br /> 18b.Allemale Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facilitys Phone: <br /> W 18r Signature ofAltemaleFacility(or Generator <br /> ) Month Day Year <br /> z <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. , !A/ 2. / 3. T- <br /> 20, <br /> Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as Acted in Item 18a <br /> fttedityped Name Signature Month Day Year <br /> Ap ph&, -.q <br /> 1,00 loz Z <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />