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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.N(anifest.Tracking Number WASTE MANIFEST +. SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ,3i5 Auto L; ni:tri Cir rvy Generator's Phone: ' 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address IRS 514N JOSE I_I_C U.S.EPA ID Number We). ��kRYkSSA ROAD "AN .',,:ii: , CIS 95133 CAII059494310 4"-444-0962 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1' HAZARDOUS WASTE LiiA 11). N.0-13. ;tr��.". !)atEf67 D0060 (BRAKE SHAVINGS WITH 13ARIN, CHROMILI irt AND I..F110) , 91 PG I I T t/4 t Z 2. :;C:RA HAZARDOUS WASIE 611L.IDS, WILY DEBRIS, ABSORBENTS), N/A 3. th 4. DE 21 2015 14.Special Handling Instructions and Additional Information ENVIRONMENTAL PERMIT/SERVICES 1)FRG#171^ . E} HR E:P++ FFNCY #1-800-468-1760 (54; / TFT) 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 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,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. [GeneratorslOffer.rs Printed/Typed Name Signature Month Day Year J 16,International Shipments F— El Import to U.S. Export from U.S. Port of ent p rylexit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a z Transporter 2 Printedrryped Name Signature Month Day Year Q F- f- 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U u- Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY