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Form Approved.OMB No.2050-0039 <br /> Please print or tope. 4 Manifest Trackm Number <br /> 1.Generator ID.Number 2.Page 1 of 3.Emergency Response Phone 9 <br /> UNIFORM HAZARDOUS t <br /> WASTE MANIFEST=.: C ACttlf#!'E�} ! .€3 .� �' b� b , <br /> 5.Generators Name and Mailing Address Generators E,te Address(if different than mailing address) <br /> 5�301EROKEE RD <br /> GeneratorsPhon'4f)W'U'-'I-'.x Xd3 <br /> U.S:EPA ID Number... <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> t�at7sr _ tYfat R ?..t ;Ot04 UNC A414 <br /> U.S:EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Facility's Phone:' wF js f f <br /> 9a 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers . .. 11 Total.. . 12.Unit 13 Waste Codes <br /> HM and Packing Group(if an . <br /> No. Type Quantity. Wt.Nol. <br /> . 1. <br /> 6 <br /> R0 ,tINII966,W "`3'V P "t'Wt.FT.} 'i,N 0 S.;?i,'.� 1 Al <br /> v� ) _ <br /> ur <br /> Z <br /> W <br /> 36 <br /> yl <br /> -3;§peciidKHdndlirrgInstructionsandAd itionallnfdrmatiori <br /> t`� {:s�°'l'L� $�i�.:s�6b° '•.. 'I a' °3yEDt ;ailC. .i:$�( .�e'fS. . ..... ', <br /> sv � iA <br /> 15. GENET; Ti 'SPOFF ROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and rccurately described above by the propershipping name,and are classified,packaged, <br /> marked'and labeled/placarded,and are in all respects in proper condition for transport according to applicable intema:ronal and national governmental regulations.If export shipment and I'am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of s;onsent. <br /> 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. Montle Dat✓Ye` <br /> Generators/Offerors Printed/Typed Name Signature <br /> 16.International Shipments; Import to U'.S. 0 Export from U.S. Port of entry/exit: <br /> i— Date leaving U S.:: <br /> Z <br /> Transporter signature(for exports only): : <br /> W 17.Transporter Acknowledgment of Receipt of materials Month ,„ Day - Yea) <br /> F— Tra port 1 Pnnted/Typed Nae d Sign ur 1 <br /> ..� <br /> IL IV .. Y <br /> CO)Z Transporter 2.Printed/T ed Name Signature <br /> Montti Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space EJ Quantity E]Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manisest Reference Number: <br /> U.S.EPA ID Number <br /> F� 18b.Alternate Facility(or Generator) <br /> Facifity'sPhone: Month Day' Year <br /> W 18c.Signature of Alternate Facility(or Generator) . <br /> 2. <br /> 19.Haiardous Waste Report Management Method Codes(ire.,codes hazardous waste treatment,disposal,and recyc€ing systems)'.. �IptlCe: State O1 alifOrnla reGlUlt eS <br /> 0 1 2. 3. generator to phoocopY and mail to <br /> DTSC with 30 daps RIV <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except nded in Item 18a <br /> PrintedlTyped Name Signature s + V i 4 <br /> Sacramento, CA 95812-0400 '-Y- <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL,COPY <br />