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!ase print or type. UNIFORM HAZARDOUS 1 Generator ID Number WASTE MANIFEST 5. Generator's Name and Mailing Addrass Generators Phone,. 6. Transporter 1 Company Name Form Approved. OMB No. 2050-0039 Page i of 3. Emergency Response Phone 4. Manifest Tracking Number JJKf h Generators Site Address (if different than mailing address) 7. Transporter 2 Company Name - U.S: EPA ID Number 8. Designated Facility Name and Site Address t, U.S. EPA ID Number Facility's Phone. ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group if an 10. Containers 11, Total 12. Unit Hf --A 9 P ( Y)) 1 No. ,Type Quantity, f WtNoi. 13. Waste Codes 114 Special Handling Insbucbons and Additional Information ( t 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, marked and labeled!piacarded, and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations. It export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) tiff am a small quantity generator) is true. Generator'st08eror's Panted/Typed Name Signature Month Day Year v ,.. -J 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/ezit: _Z Transporter signature (for exports only): _ Date leaving U.S.: � 17. 1 tansporterAcknow ledgment of Receipt of Materials ua Transporter 1 Pnnted(Typed Name Signature Qra Month Day Year z Transporter 2 Prnnted;Typed Name 18. Discrepancy 98aDiscrepancy Irdicagon Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Re ciin o )e ❑Full Rejection 18h. Alternate Facility (or Generator) P.lanifes! Reference tJumher; 5 U.S. EPA ID Number 0 Facility's Phone: uj 18c. Signature of Alternate Facility (a, Generator) 4 Month Day Year U.) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment�ul and recycling syslems) 1 2. Notice: State of California requires generator to photocopy and mail to 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Itern 18a Pnnte(v typed Name Signature FAT --,m8700-22 (Rev. 12-17) Previous editions are obsolete. " a °' i 1 "1r` ' ( � {30 t lftiNk7KA i OR"S WITIAL COPY