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Please print or type,(Form designed for use on eli4(12 itch) pawritac) Form roved.OMS No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pape 1 of 3.Emergency Response Phone 4. an ng Number WASTE MANIFEST r w}:flil0 1 1415-823-8772 5.Generator's Name and Melling Address Generators MeAddras(adifferent than mailing address) r GenaraWr's Phone: Transporter , pang Noma U,S.EPA ID Number 7.Tran outer 2 ComF9y_Re M___ U.S.EPA ID Nur 6.Designated Facility Name a@ We Address US,EPA ID Numhar t i ii i} li phonW-444,44131 Eat Carhon,U1 B4520 U SA 90. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12,Unit 13,Waste Codes HM and Paoldng Group(If any)) No. Type Quantity WtNol, 1, r;m' r-res en. i'c,-.°.-_ 1_ .s C;' o-n •r a°rtE row:, ^re �sU0VVr �r,.111A_n W1.14L"i aE to trrsl u`} n°, est D , rWzr� 2, 3. 4, 14,Special Handling lnsaucdons W Additional in r.hliio-. '3ffVQWe Reillycil-INGR t:T � , RAX.OM NO. 4F;4. qtj 05 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this conslpmortt are(utiy and accurately described above 5y the proper shipping name,and are class4iod.packaged, marked and labe(edlplacarded,and era in as:aspects In proper condition for transport according to appkcable international and national govemmentat regulations.If export sMprnent and 1 am the Primary Exporter,i certify that the contents of this consignment conform to the terms of the attedied EPA Admowledgment of Consent (certify that the waste minimimtion statement identified in 40 GFR 262.27(a)(H i am a large quantity gam enerator)or(b)(1I I a oma#qusrrtiiy goneretor)is W e. Tons a n me re y ear 1Y1.6I/Y. 16,international Shipments ❑import to U.S. ❑EW fom U,S• PGrtofentry1ma. Transporter signature for exports only): Data I!LVN U.S.: i ir 17.Transporter AOmMedgment of Receipt of Materials Transporter 1 PrinladlTyped Noma Signature y iTransporter 2 Printuffyped Name re Month DAY Year Discrepancy 18a.Discrepancy lndtcartion Space Quantity ❑Typa ❑Residue. ❑Partial Roction ❑Fug Rejaceon' McNfast Reference Number 18b,Alternate Faddy(or Generator) U.S.EPA ID Number j U LL Fadii a Pho : 180. ArafuraneTemate FOiJ (or naraWr} - Month ay Year 19.Hazardous Was Report Managannerlf htetl 0 i nodes(i.e.,codes for,hazardous waste treatment,d4osal,and recyci(ry ipbsnA 1. 2. 3, 4; 20.DesignatedFedlity�OmororOparatnrCertihcatlonofrec�iptoftiaardaua.metaials db ythemanbsteirc5pt®siief initamlea _ MadrTypad Nome „ ipnanxe y e r EPA Form 5700.22(Rev.3-05) Previous editons.are obsolete. DESIGNATED FACILITY.TO GENERATOR }