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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM NAZARDOUS 1.Generator ID Number Page 1 of 3.Emergency Response Phone 4.Manifest Tracking.Number .„ MANIFEST a ti n '.i ! r' 2. . 91637'l-x747 JJ K 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) 1"w'13'scraimnixt Rd. :4�l�A�l t��,fllSri+�te I-OvI adbelge CA, Generators Phone: . 6,Transporter f Company`Name U.S.EPA ID Number R• rias iEr'14'i1`t7nmentJlill 4Ser'ims Inc. CA 00 4 4 0 0 3 15 5 8 7.Transporter 2 Company Name U.S.EPA ID Number 4 8.Designated Facility Name and Site Address U.S.EPA ID Number is.':;3ti=tie I��:3;JCuC+ ery 3156 E.Pico Blvd LOSA WI&S CA 00023 Facility's Phone. r= ,ry ,,,;�• ^ " " n L. ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group If any)) No. Type Quantity WtJVol. 1. 4.f';' 831 IC :Cl4r�ilYft x.. r4 � r 2. 3. 4. 14.Special Handling Instructions and Additional Information prolel# ER---V333 E.R.Comaaar.Rams EnvirerimL41all hadders ski be trsined and use al:i Pl 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 Iabeledlpiacarded,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 o@rti[y that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 44 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. GeneratorslOPferor'si'rsnted(ryffpeSignature Month Day Yeard dame 9 , 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entryfexit K Transporter signature(far exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printedffyped Name Signature Month Day Year O Z Transporter 2 Printedityped Name Signature Month Day Year Q F- 18,Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U rQi Feidliys Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Q 1. 2• 3• 4. 4 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY