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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Qoclo ► ��� 8s8 -$��-�2t� 019703519 JJK <br /> 5.Generator's Nam not iling gds a Generator's Site Addressdi(fereAl than n 'inf�address1 <br /> UAV11avl t i1G ,� 1U1+ �oA� � a� l�v�i �CCC�� t �1Y11GV1 �tCn �-C Y1ra�d <br /> b'S2o Co.�1po✓atQ, 'prwQ J ,ddo E' �i?�t1n Rd, <br /> GeneV7orsPlhone�°Isbs� IN yba (q1b S 'Q`i`�� 1 rC.tY�1 CA llTZSq <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> t� ' fi �nveY � rvi Q 386b�R�} <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.f sig0naStd Facili�tylName Ve-V OA U.S.EPA ID Number <br /> Ib�o }V�vJ' �al� SN-ee-1" <br /> Bim►, CA go8&3 c� oz$�lo�►0►9 <br /> Facility's P ne: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> ' nJov►- (ZC.�1 }tc>lzca✓does �- �- 5a <br /> 9 (, and Mc6w f <br /> 1 'pYl 2So P <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14,S e ial Handling Inslructio nd Ad itign I Inform i <br /> II-20-IW1 IK <br /> Of it 439 LA Plff,;,93-/ <br /> wi2-wanof <br /> 15. GENERATOR'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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Generator'slOfferor's Printed/Typed N me Si ure Month Day Year <br /> .j 16 In rnalional Shipments <br /> ❑Import to U.S. Export from U.S. Port of enirylexil: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> o an l Zo -Z0Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ran Facility's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1, ��/ 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print ypame Signature Month Day Year <br /> 9 P/>QS161 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. IGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />