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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 Phone4.Manifest Tracking Number WASTE MANIFEST -��9 24 1 . 006680711 JJ 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) 109 V @wt07 Ave &Gtp DEC 12 2012 Maeacaa,CA 95337 Generator's Phone: k ` ti 6.Transporter 1 Company Name U.S.FPA ID Number For M==E 4'jZftrM--A'D S-mA ,km CAROM179097 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number US E ,! f,- 1f 05 �vJs 3 GV CY le @GFC3 90II�9 Facility's Phone: 7 7�j ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Pacidng Group(if any)) No. Type Quantity Wtivol. 1. ri r "i- Td . 0 t,r ocl o R;sr�i��G3A��ni��f�ui9c:�:;.C, 5i�,�O)B! C�n?�,u�i'�2n�1[��aC,��3) � �y�� M115' @/ W Z 2. W 3. 4. t 14.Special Handling Instructions and Additional Information q01 ) 0 ; % y Ae bi 15. GENERATOR'S/OFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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,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)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generatoes/Offemes Printed/Typed Name Signature ` Month Day Year iocm 16.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port ofeta exit: Transporter signature(for exports only): Date I ruing U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter t Printedrryped Name Signature Month Day Year QTransporter 2 Prl to Vyped ame ' Signature Month Day Year II,I - �v t t 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reject-- Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V tQa. Facility's Phone: - 11 Lu t8c.Signature of Alternate Facility(or Generator) Month Day Year Q Z a-i19.Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) U. 1, �)J,3 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 `Sig a Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR