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Please print or type. Form Approved.OMB No.20SH039 UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3 Emergency Response Phnno 4.Manifaat Tracking Number WASTE MANIFEST 001722422 VES 5 Generators Name and Mailing Address Generators Site Address(d different than mailing address) YULISSA GALVAN FED EX GROUND SAME 5655 HOOD WAY jWPZno;A 95377.7717 enera s 6.Transporter 1 Company Nana U.S.EPA ID Number VEOLIA 9 TECHNICAL SOLUTJQNS IN J D 0 8 0 6 3 l 7 Transporlm 2 Company Name U.S.EPA ID Number 8 Dwgnaled Facility Name and Site Address U.S.EPA ID Number VEOLLA E5 TECHNICAL SOLUTIONS, L.L.C. I 7 5 HENSLEY STREET Fact utys Phone: RICHMOND,CA 94801 C A T 0 9 0 0 1 4 0 7 9 93 9h U.S.DOT Description(including Proper Shipping Name.Haxand Class,ID Number, 10.Conte ne€s 11.Total V.Unit HM and Packing Group(if any)) 13.Waste Codes Nv. Type Quantity W1.No1. Y t' UN3159, 1,1.1,7-TETRAFLUOROETHANE, 7.7 331 I C V 5 P 2. 0�-RCRA HAZARDOUS PASTE LIQUID,t�I.ATEX AAINT, 331 7 D F 475 P 3 4 14.Special Handling Instructions andAdditionol(information ER Service Contracted by VESTS + Contract retained by enerator confers APT, ,mith 00T ojV:��iniS�A�71529°r substitute additional transporters vn generator's behalf -I I�ERG:17d W:187976 15 GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, marked and labeleWplararded,and are in all respects'm proper oondibon for transport according to applicable ntemational and national governmental regulati ris.if export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of ttie attached EPA Acknowledgment of Consent. I certify Thal the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantitygeneratar)or(b)(91 am a small quantity generator)is true. GeneUlfer,, ritedriypedName Signature Month Day Year 'figI ' CSG vn S' 2� 116.Intema anal Shipments ❑Import to U.S. ❑Export from U.S. Part of entryfexik ? Transporter signature(for exports only): Data leaving U.S.: w 17 Transporter Acknowledgment of Reoeipt of Materials Q Transporter 1 Pnnledrtyped Name Signator / Month I Day a ,_v/ g Z Transporter 2 Pdntedffy Name Srgnalure Month Day Year 9 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residua El Partial Rejection ❑Full Rejection Manifast Reference Number: 186 Allemale Facility for Generator) U.S.EPA ID Number U ia+ Facility's Phone UA 18c.Sgnalure olkemale Facility for Generator) Month Day Year a z 19_Hazardous Wasle Report Management Method Codes(!.a,,codes for hazardous waste treatment,disposal,end recyOng systems) a 1. 4 1q 2. 3. 4 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a rant d!€yped Nam igaature Month Day Year Gc- 3410;0^0-4 1rS EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM