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Please print or type (Form designed for use on Hite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 9 of 3.Emergency Response Phone 4 Manifest Tracking Number SKS(� WASTE MANIFEST SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) F00;.11 iller [fir 43Meat^Ipo S:s. Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number F.M8 1 NL 7.Transporter 2 Company Name U.S.EPA ID Number r 1 a`I.';MENTAL SVC INC. 8.Designated Facility Name and Site Address U.S.EPA ID Number 1021 PERRYESSA ROAD SAN JOSK Facility's Phone: 408-441 .0 Y1_;i: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quaniity Wt.Nol. IX 1.Wlhw' WAAWI HAZARDOUS WASTE EXUDS 0 52 Z 2. w O 3- 4. 14.Special Handling Instructions and Additional Information MDii 4 PP ' i>4"f!".► h:t'^+ iy.i=,P-.t'af—,ir3 ; 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment 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)(if I am a small quantity generator)is true. Generator's/Offeror's Printed,Typed Name Signature Month Day Year r 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: UM 17,Transporter Acknowledgment of Receipt of Materials Transporter i Printed,,Typed Name Signature Month Day Year O a Z Transporter 2 Printed/Typed Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U < Facility's Phone: LO 18c.Signature of Alternate Facility for Generator) Month Day Year d z S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU t. 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,7yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY