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Please print or type. 1.Generator ID Number Form Approved.OMB No.2050-0039 FUNIFORMRDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number EST - + � z ��nrsa Generator's Site Address(if different than mailing address) ast Jetleson St get Stocktorl, CA 9S' 2()6 64U i--aSl Jelterson 5U'et Generator's Phone: _ StoCktm, CA"206 6.Transpg�te�ti Comp�py Name, �,` U.S.EPA ID Number }"', mow,w'1,�A,Y Contactim 7.Transporter 2 Company Name 4�,f�$�a7�+�q$ U.S.EPA ID Number" n 8.Designated Facility Name and Site Address iva LLC U.S.EPA ID Number 11865 Whit Rock fid.-RanCho CordBVa,C,95742 Facility's Phone: (916)351-0980 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes No. Type Quantity Wt./Vol. 1' UN-'z -;a, s:' sale�oint Related Materials, 3, PG If fJf t 9; � Z 2. LU c9 3. 4. 14.Special Handling Instructions and Additional Information cam:Wow i i t"iA sot I K�a� JM".3Ji`., PPSVYIwth��tgMY�it�� P woodli CHINIFT111111M rt -C*411 to PA11K Job* 369103 15. GENERATOR'SIOFFEROR'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 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 EPA Acknowledgment 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)IN am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature OMonth Day Year a _._ z Transporter 2 Printed/Typed Name Signature- d Month Day Year a 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type Residue❑ ❑Partial Rejection ❑Full Rejection ❑ Manifest Reference Number: F 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p UJ 1 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 Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY