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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 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ltaLir, ;;,'• _;' y`r *.�: FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) 'Jnf-,KTl CA C,5?04 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number ':.)•aEi;t::t4? Gsw4rtit.r:l 46iibiii,i( sir. /l)RA ?1t'-f•I:NVN i 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number t,AvEr Lt A ifC'wrtegv 6133 Edith Blvd NE Akv.,q-wqq to, NVA 8 7 10 r' FacilitysPhone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10-C 11.Total 12.Unit HM and Packing Group(tfany)) 13.Waste Codes No. Type Quantity Wt./Vol. 1 � ¢0LLJ -- — -- z 3. rti r t n:°v sirii'.f:1it it I t" I V_i.??if 7ZI;€_ :fi t I i j 4. I _ J 14.Special Handling Instructions and Additional Information L ri 14),4, X)4- ;) V,18244e'.K)A- - J' 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 intemational 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. enerator rocs7 yped Name signawre Month Day Year r 16.Inlemational Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit Transporter signature for exports onl : Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials IF—Ce Transporter 1 Printedrryped Name natureM ay Year OCO I I I Q' Transporter 2 PdntedrTyped Name Signature Month Uay Year H 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes i.e.,codes for hazardous waste treatment, y Po 9 ( disposal,and recycling systems) C1 1. 2. 3. T- 20. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in flem 18a Prinled/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.305) Previous editions are obsolete. GENERATOR'S INITIAL COPY