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PI ease print or type. iForm designed for use on elite (12-pitch)44Ewdter.) UNIFORM HAZARDOUS 1. Generator ID Number WASTE MANIFEST 5. Generators Name and Mailing Address rp.m.rator's Phone: Transporter 2 Company Address Facility's Phone: 98gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (if any)) 1. LLI Z 2. W L9 11111111111 8 Page 1 of r1mergency Response Phone Generator's Site Address (if different than ml o Form Approved. OMB No. 2050-0039 ing Number -i GBF J.S. EPA ID Number U.S. EPA ID Number U.S. EPA ID Number 10. Containers 11- Total 12. Unit No. Type Quantity Wt.Nol, 13. Waste Codes 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aowrately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, 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 terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282.271a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneratorslOfieroi PrintedfTyped Name Signature Month Day Year —1 15. International Shipments1:1 Import to U.S. ❑Export from U.S. Port of entrylexit: Date leaving U.S.: = Transporter signature (for exports only): W 17. Transporter Acknowledgment of Receipt of Materiais Month Day Year Ir Transporter 1 Printed'Typed Name Signature O 4 •s ,..- .r` I - Mon Day, Year QTransporter 2 Pn ype Name 5ignatdre' LLQ r- 18. Discrepancy ❑Residue Partial Rejection ❑Full Rejection 18a. Discrepancy Indication Spam El Quantity ElTypeManifest Reference Numher: U.S. EPA YD Number 18b. Alternate Faeility (or Generator) J_ U Facility's Phone: Month Day Year W 18c. Signature of Alternate Facility (or Generator) z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, dispOdisposal, and recycling systems) LU 1 z. Notice: New federal form. State of 0 California requires generator to photocopy 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and Mail to DTSC within 30 days: Signature P.O. Box 400, Sacramento, CA 95812-0400 PrintetllTyped Name 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY