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Please print or type. Farm Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1 Gerreratnr ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST '1')-611- 09352 JJ K 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 B.Designated Facility Name and Site Address U.S EPA ID Number Facltity's Phone go, 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HIM and Patting Group(If any)) No. Type Quantity Wt.lVol. 13,Waste Codes 1. oc aO r7C Z 2 W f� 4. 14.Special Handling inslructions and Additional Information 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. marked and lauale6placarded,and are in all respects in proper condition for transport according to applicable intemationaland 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantitygeherotor)or(b)(III am a small quantity generator)is true. Generator'siOfferor's PnntedTyped Name Signature Month Day Year J 16-International Shipments ❑Import to U.S. ❑Export from U.S. Pori of entryiexlt: Transporter signature(for exports oniy) Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Ix Transporter 1 PrintedlTyped Name Signature Month Day Year O a Z Transporter 2 Primed.+Typed Name Signature Month Day Year 18.Discrepancy 18a Discrepancy Indlcatlon Space ❑ Quantity ❑Type ❑Residue ❑Parlial Rejection ❑Full Rejeci Manifest Reference Number: 18b,Alternate Facility(or Generator) U S.EPA ID Number +J LL Facility's Phone: LU Inc.Signature of Altemate Facility(or Generator) Month Day Year Q Z 19,Hazardous Waste Report Management Method Codes(i,a.,codes[or hazardous waste treatment,disposal,and recycling systems} 0 1 2 s Notice:State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Dparalor Certification of receipt of hazardous materials covered by the mandest except as nded In hem 18a DTSC with 30 day s: PrinlediTyped Name Signature I BOX 400 Sacramento,CA 9S812.0400 EPA Form 8700-22(Rev.12.17) Previous edit are obsolete. GENERAL UK a nrr i.—