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7/0 12-0 Form Approved.OMB No.2050-0039 Please print or type. UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma6171 n`*ffest Tracking Numl1er w WASTE MANIFEST v 1 7 1 tom' �, ^'' FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6,Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 9a 91b.U.S.DOT Description(including Proper Shipp g Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. ce — — - O I Z 2. w c9 3. 4. 14.Special Handling Instructions and Additional Informati n 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I I iereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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 consignmf int conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identi fied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. Generator's/Offeror's PrintedfTyped Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: I= 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed[Typed Name Signature Month Day Year O CL Z Transporter 2 Printed/Typed Name Signature Month Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 1 z 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification(greceipt of hazardous materials covered by the manifest except as noted in Item 18t DTSC within 30 days: PO Box 400 PrintedlTyped Name Signature Sacramento, CA 95812-0400 EPA Form 8700-22(Rev.12-17) Previous editions ar obsolete. GENERATOR'S INITIAL COPY