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Please print or type. Form Approved . OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin umber WASTE MANIFEST C AU"1045'YJI I £ 7�tt 4 ?4 31 3452 F L E 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) V�Ie+tt 13ms (7Lirwrete PkmVing 28189 K 14ewwwr : , 1 D24 plw Ilw" way tar�it , i-A 95632 Com , CA. WAV Generator's Phone: 7 6, Transporter 1 Company Name U .S. EPA ID Number r , lean , IT v"v 7. Transporter 2 Company Name U.S. EPA ID Number 8. Des,ignated Facility Name and Site Address . U.S. EPA ID Number r'aoft ff91'hlltt m fiv►-` 31 wo V010 plot) "MI04mlyd Los Angeles , CA 9l?C12&X',.VM _ Facility's Phone: IW "49W 7145 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 Packing Group (if any)) No. Type Quantity Wt.Nol. X 1 • NAI093 , Waste Qwhkmtitllet ntlid . N 0 S , PM (Waste dieselhtel) Dbi DM 55 G a z 2. LJ 3. 41 14. Special Handling Instructions and Additional Information } wv*q l flleI ER(.7#t 219 ( twiritrer . 80),42443110 g r b 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 internationaland*national•govemmentalfegulations. 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 � . I certify that the waste minimization statement identi .in-40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantitygenerator) is true. Generator'slOfferor's Printed/Typed Name Signature Mont Day Year M' 1 J J C 16, International Shipments I F ❑ Import to U.S. ❑ Export from U .S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.• "1 W 17. Transporter Acknowledgment of Receiptof�Materials LU Transporter 1 Printed/Typed Name Signature t Month Day Year ZTransporter 2 Printed7y'ped Name rl Signature r Month Day Year F- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Typej j ❑ Residue ❑ Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number L) Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year a z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1 . 2. 3, 4. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded 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