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Please print or type. Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number F2Pa,,e of 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST r.iilL 1214163 :ii 7;i f '1 -+,> §,,,• !ft <br /> U ,�,l JJ K <br /> ts .. <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 0F'.AR[tNT>RPFIWc' <br /> r <br /> N Ti-i'_1='F:E �. f.//A. <br /> ViCKTON,CA. 95-M- <br /> Generator's Phoria;'' <br /> U.Transporter I Company Name U.S.EPA ID Number <br /> R�4i'40S) EtiP•.11f*,C1A1Iv1EttlTril ER'J1 If-IC. r..,.y, ,,,,.,ir..>• <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address:.;4,r11-.)S F N,Ag(-)NkiEWAL 4>FRVICEiS WL U.S.EPA ID Number <br /> WEST&ACRAPr1CAiTt:r,G•.r4 %gl <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. ilL11+I ht t=t tl�...yKllti LI`•/F`'.'>tF ;f')�1t;) frJ11., f1F`EiRr } ti+,. <br /> 0 <br /> 1 <br /> Z 2. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> .7Jhh-i_1S kit(':''ii:'{ A_'•G, ��G��Ly <br /> e.r;�!'c:(�7atT1~.�k4re,►<: r��ftaa� �r�(.�:1Frlf�,l�tdT�•1.. <br /> ii.4}.DI.[R"x 'vH0tX9 E?E TF(Aji gIF6 p1dD US.E.APF'rzolva) PPF <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignmer tare fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to ap icable international 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 EPAAckno viedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff I am a large quantity gE neralor)or(b)(ill am a small quantity generator)is true. <br /> Generators/Offeror's Printed/Typed Name S gnature Month Day Year <br /> j 16.International Shipments / <br /> 1:-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LU <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed,Name <br /> Signature Month Day Year. <br /> zTransporter 2 Prigled/Typed Name Si nature Month Day I Year' <br /> !— <br /> 10.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑T e <br /> YP El Residue ❑Partial Rejection ❑Full Rejection <br /> jZ <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facilitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,dispos ,and recycling systems) <br /> 0 1. 2. 13.- <br /> 20. <br /> - -- <br /> Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the mani est except as noted in Item 18a <br /> Printed/ryped Name Sig iature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />