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Please print or type.(Fonxdesignad for use on elite(12-pitcA)-*wnter.) Form Approved.OMB No,2454-0439 UNIFORM HAZARDOUS1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST I 'C A .D A 8 2 5 0 8 2 5 1 1 xk_889-51K117 0 0 0 2 0 2 6 9 JJ K 5.Generators Name and Mailing Address Generatoes Site Address(if different than mailing address) f1mfted Wet tem Gko e7ry U.1P G# 'Ath:Pat WknTtrw*ty.5,200 SWfa_1�11ci-jei 19W F'iccclf Rd, ic>srt wce CA 9W40 96216 Generator's Phone: 6.Transporter I Company Na. U.S.EPA ID Number Haz Mat Trans. hic. C. A T 0 8 0 Q T12 3 0 0 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address, U.S.EPA ID Number Gros]y&Oveflon 16,10 V'+t. t Ah S111reet Long Bch C-A f90813 Facility's one: y .� c r i ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt./Vol. a 1 VVAS'F E Ae*% me, 343 ! ' /- �r�''i'�`••"fir '' 4'F P ZLU 2. 3. 4.. II 14.Special Handling Instructions and Additional Information i :?5:.2 1,1,w• 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are futly 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[am the Primary f Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. -1 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. GaneratorslOfferors Printed7Typed Name Signaturee', ;`Month Day ' Year I 16.Intemationat Shipments', ❑Import to U.S. ❑Export from U.S. Port of wrylexlt: Z Transporter signature(for exports only): Date leaving'U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials _ Transporter 1 PdnlgYlypel Name - Signature; Month Day Year Q ransporier 2 PrintedrTyped Name,, Signature ,." Month 'Day Year 18.Discrepancy t8a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑.Partial Rejection ❑Full Rejection' Manifest Reference Number. 18b.Attemate Facility(or Generator) U.S.EPA ID Number _ u- Facilitys Phone: 18c.Signature ofAltemate Facility(or Generator) t Month - Day Year 19.Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1, 2. 3. 4.- 24.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Be PrintedlTyped Name Signature Month Day Year. EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY