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r - Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST G A i.u u(]3€3 1 '' ?- t :!;i i f 8 7 0�. =` JJK_ 5.Generators Name.and MailtngAddress Generator's Site Address(if different than malting address) ADVANCED POLYMER TECH 3837 IMPERIAL WAY L-117OUKTON CA 9:5215 Generators Phone: 200 464-27.01. 6.Trans��rer i Company Name U.S.EPA 10 Number tiJCmR.I-D c SII.1.101PON MENTAL SERVI GES CAD 0 2,9 2 7 7 0.3 6 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Dr_i-rF14NO/KEk DOO,id 2000 P4.ALAMEDA STREET C4t-APT0111 CA 9 02.2 2 Facgily's Phone: ($10)537•?Im ga. 9b.U.S.DCT Descrlplim(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.-Unit 13:Waste Codes HM and Pack-Ing Group(if any)) �No. Type 4uani ty Wt.N01. UN1993.WASTE Fi-Am 4tABLE LIQUID, N 0:9,.(INK). 31 PO I9 � z 2. W 3. .4. 14.Special Handling Instructions and Additional Information BIERGGENCY CONTAOT:CHE NITRFC 1-800-4214 9300 WOES TERMINAL:CE RES CS IPROFUE 0 0131:0727�]f9-03 INV * ' APPROPRKTE PPE:FQUIPPAIENT 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 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 consignment conform to the terms of the attached EPAAcknowledgmeht 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. Generatorsl08ercrs Priniedayped Name Signature Month Day Year _J 16.Intemation�Ahipments r ❑Import to U.S. ❑Export from U.S. Port of entry/64: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter,l FrintedlTyped Name Signature Month Day Year aco ZZ Transporter 2113rintedlTyped Name Signature Month Day Year f- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity 0 Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V rai Facility's Phone: w 18c.Signature of Altamate Fadllty or Ganeralor) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1 r1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY