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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.Manifest Tracking Number WASTE MANIFEST G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 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 ('{,-t U.S.EPA ID Number 171f)Pf'rOVA r�.A 0-5741 Fatuity's Phone: 9a 91 US-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 W1.1vel. O r— Z 2 LU 4. 14.Special Handling Instructions and Additional Information 15. G EN ERATOR'SfOFFEROR'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 labeiedlplacareed,and are in all respects in proper condition for transport according to applicable intemationai and national governmental regulations.If export shipment and I am the Primary Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 k am a small quantity generator)is true. Generator's101ferors Prinledffyped Name Signature Month Day Year 16.International Shipments ❑import to U.S. Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Dale leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LLI or Transporter 1 Printedlfyped Name Signature Month Day Year or CL Q Transporter 2 PrintedlTyped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantityyp ❑T e ❑Residue [A Partial Rejection Full Rejection Manifest Reference Number I 6 Alternate Facility(or Generator( U.S.EPA lD Numbar U u- Facliity's Phone: S 18c.Signalure of Alternate Facility(or Generator) Month Day Year a ff Z I. Fn19.Hazardous Waste Report Management Method Codes(I e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. Notice: State of California requires aeneratorto photocopy and mail to DTSC 20.Designated Facility Owner or Operator:Certificalion of receipt of hazardous materials covered by the manifest except as nded in Item within 0 day's: rintedffy ped Name Signature P.O_ Box 400, Sacramento,CA 95812-0400 ar EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY