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Please print or type. Form Approved,OMB No.2050-0039 E UNIFORM HAZARDOUS t.Genarator ID Number 2.Page 1 of 3.Emergency Response Phone 14,Manifest Tracidnp Number WASTE MANIFEST 427Z)21 1 0017969 VES 5,Generator's Name and Mailing Address YULT88A QALVAN Generatols Site Address(if diflarantthan mailing address) FTS MC GROL>l+➢] SAME sass H0013 WAY &Mgl":95377-7217 6.Transporter 1 Company Na n 630-25M U.S.EPA ID Number N ] ID a It 4 6 3 1 3 6 9 7.Transporter 2 Company Name U.S.EPA 10 Number r 8.Designated Facility Nerve and She Address U.S.EPA ID Number VBaLaA EN TBCKWAL WUMC r1el, r L.L.Q. T TZ HENBLEY ffrKE sT Fadi s Phare: 1iTCHISMVI�CA 941101 go. 9b.US.DOT Description(including Proper Shipping Nanta,Hazard Class,10 Number, 10•Containers 11.Total 12•Unit HM and Packing Group(Hany)) 13.Warta Codes No. Type Quantity YOtlVci• o X NA9077,�rAZARDtxm WAS'C8,SOLM,woo„l 3RY Hoag 0 x+uICKEOCEM Lams),9,m T D F 21 P 181 LU 2. A M-RCRA HAZAItDOTJ8 WAWE LlIQLAA(MUCC8E8„ 331 cal) ! 2 D M 494 P 3. 4. I 14L Fpeclal Hundl ng Inshdons and Additional Inforrnatlon ER&nuke CWcho led by VtsM + Conhwt tet.,oed by ear � on lolls"twm a w 1n W at sabetWA boop wilan on gp�tmmo trg behat[ + 1 FIR0171 W54 A: r= W.71529 AWA671529 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ars fully and accurately described above by lire proper shipping norm,and are classified,pocketed, marked and labaiedlplacarded,and are In alt respects in proper condition for transport according to applicable intem§§nal and national governmental regulations.If a)Wdshipment and I am tho Primary Exporter,I certify that the contents of this ocnsignment conform to the terms of the attached EPAAcknowledgmentof Consent. I certify Mot Bre waste minimization statement identified in 40 CFR 262.27(x)(ti 1 am a large quantity generator)or(b)(tf t am a small quantity generator)is true. Generalor'slOfferces PdnM7yped Name w Signa Mmth Day Year Y 1�\ ,•,,,s 16.In1amatlortalShpmenls ❑Import to U.S. ❑Export tram U.S. Port of entrylexil: Transporter signature(for exports only): Date leaving U.S.: C9 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PdntedlTyped Name Signature Month Day Yeer a Transporter 2 Pdnledffyped Nam Slgnafure Month Day Year 118,Discrepancy 18a.Discrepancy Indication Space ❑ Quandly ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(o(Generator) U.S.EPA ID Number i� LL FadliVs Phone: LL, 180•Signature ofAltemate Facility(or Generator) Month Day Year HR.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 20•Designated Facility Omer or Operator.Certffication of receipt of hazardous materials covered by the mandasl except as noted in Item 18a Print yped Name II,, Signature Month Day Year Af N+•141jo M EPA Form 87022(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's a»MANIFEST SYSTEM