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lease print or type.(Form designed for use on elite(12-pitch)typevrriter,) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 11.Generator 1D 'mber (�{J��7 2.Page 1 of 3.Emergency Response Phone 4.Manlfest Tracking Number WASTE'MANIFEST # U"V V — ®®� ®®� �� 5^^ngraor' Narge�,!gfl' A ess Generator's Site Addr (ddifferenttha aili a dress Generators none: - 6.Transpod rt Comp yNa a U,S.EPA IDNumber 7.Tran oder 2 Company Name U.S.EPA fD Number 8.Designated FacilityNa e and S•sAddress U.S.EPA ID Number CA Faality'sPhone: ga• 9b.U.S,DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers ]it.( and Pecking Group(d any)) 1 f.Total 12.Unit 13.Waste Codes 1 , No. Type Quantity WWo1. i 2, 1 3. 4. 1 Ial Handling ID5 ct(ons and Additional Information �± 0 -33 15, GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper sWppfng name,and are classified,packaged, marded end labeledip!acsrded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and t am the Primary Exporter,I certify that tha contents of fhts consignment conform to the terms of the attached EPAA*%vledgment of Consent certify that the waste minimlzatfon statement Identified in 40 CFR 262.27(a)(d I am a large quantity generator) if I am 'sma8 quantity generator)Is true. neralot's/0 rime yped Name S1gnaEur �3 Month Day Yea t7 r—e t 16.Intemational ipmenl j Import to U.S. ❑Fxpod from U.S, Port of er" "axil Transporter signature(for exports only}: Date leaving U.S.: 17.TransporterAaknovAedgmenl of Receipt of Materials Transporter 1 Pdrn 0 a ame Signature' 01 /. �— Month Day Year Transporter rinled/T Name Signature . h nlh y Year 18.Discrepancy 1Be,Discrepancy Indication Space ❑ Quantity ❑Type ❑Res!due ❑Partial Re'coon 1e ❑Full Reection 8b.Afternate Faalily(or Generator) Mzn fes!Reference Number. U.S.EPA ID Number =adliry's Phone: I 3c.Signature ofAltemate Facility(or Generator) Month Day 'Year 9 "--ardous Waste Report Management Method Codes Re.,codes for hazardous waste treatment,disposal,and recycling systems) 2 3• 4. 0.Designated Facility Owner or Operator.Certification of iecaipt of hazardous materials covered by the manifest except as noted In Item 18a . ' nledfryped Name Signature Month Day Year crm9700-22(Rev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO DES►INNrION gTgtr-;(IF.REWIRED)