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Please print or type. Form Approved.OMB No 2050-0039 UNIF=ORM HAZARDOUS 1.Generator ID Number rage1 of 3.Emergency Response Phone 4. nif st TrackingNumberWASTE MANIFEST A R 0 0 0 .2 6 6 2 � r� � VES 5 Generator's Name and Mailing Address YUA(W�VAN Generator's Site Address(if different than mailing address) .%HOW WAY Generator's Phone: 2 6.Transporter 1 Company Name U.S.EPA ID Number VMXJA"711l-AT.q'l T717WIr- 7 Transporter 2 Company Name U.S EPA ID Number Wil -9MVIM E7 6 2 A 7 A 8.Designated Facility Name and Site Addre s'iilill ��H]rf1L'.Ag.��„�� U.S.EPA l D Number 1125 Ul STRW Facility's Phone: 511'1 233.&X]t RXXIIIIIIall CA 9/>l I - A T 0 R n {'i 3 Al 11 0 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Ouantlty WtN13 Waste Codesoi. w L 2' (Will HATA'ftI]Q'Z]fi WASIT I AlUjl]r,(l.A'3j1;PAll 1) F 600 —- 3. 4 14.Special Handling Instructions and Additional Information lR$1RCOMMil by YE8 + =Me"by ValmUm Gumbo IMI SII Blfril�14�dl!OR ftl i Olpr0!!11(D ] O`�"S4 W:1#1fN:,f29 OP }PT�IS Zj W:7139A:P Allrf]524 15. GEN ERATOR'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, marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true, Generator'slOfferor's Printed/Typed Name Signature Month Day Year 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entrylexit: 9 Transporter signature(for exports only}: Date leaving U.S.: IX W 11.Transporter Acknowledgment of Receipt of Matenals ji Transported 1 PrintedlTyped Name Signature Month Day Year O CL Transporter 2 PrinkedfTyped Name Signature Month Day Year F^ 18,Discrepancy 18a.Discrepancy Indication Space ❑ ouanG 1:1T Residue ty Type ❑ ❑Partial Rejection ❑Full Refection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number .:a U Facility's Phone. LU 18c,Signature of Alternate Facility(or Generator) Month Day Year a z 0 19.Hazardous Waste Report Management Method Codes(i_e.codes for hazardous waste treatment,disposal,and recycling systems) CI? 0 1 . 2. 3, 14. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY