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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. Manffest Tracking Number WASTE MANIFEST ;tea �o- Q 19 5 4 4 3 6 JJ K 5. Generator's Name and Malling A""%WM W+W a ftVft Generator's Site Address (If different then mailing address) 1MT0@kAh* #3= la + �>�� AdIVl Tadrlp1lsC CA 4!? Us* CA Vii, Generator's Phone: 6, Transporter 1 Company NameANN YOM (M 811fYlfMi U.S. EPA ID Number �a 7, Transporter 2 Company Name U.S. EPA ID Number 8, Designated Facility Name and Site Address OWN ft him U.S. EPAID Number s l= 8&ba Lai Al CA Ono!] 504"4111111114 FacillVs Phone: 9a. 9b, U.S. DOT Description (including Proper Stripping Name, Hazard Cfass, ID Numt:er; 10, Containers 11 . Total 12. Unit M and Packing Group ('d any)) 13. Waste Codes No. Type Quantity Wl.Nol. ' tld+- H90waw+ t i� �} ! TT 0 221 LU z 2. 1f a W 3. 4. 14. Special Handling Instructions and Additional Information 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 Ia4eledfplacarded, and are in all in proper condition for transport according to applicable International and national govemmental regulations. If a shipment pmeni and i am the Primary Exporter, I certify that the oordents of this nment oonform to the tarns of the attached EPAAdmowledgment of t I certify IhM the waste minimizations jdenIffied in 40 CFR 262.27(a) (d I am a large quantity generator) orl am a small qt an ' tor) is true. Genera sl roes Printed lf Na FMonth Day Year 16. International Shipments/ ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit ? Transporter signature (for exports only): Date leaving U.S.: 17. T r Acknowledgment of Receipt of Kiedaw UJI Tr Printed/typed Name Month Day Year O ! RL l Z TraMportat 2 Pdnted/fyped Na U) �4/z re /F Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: F 18b, ARemate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone: LU Ilk Signature of Alternate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatrnent, disposal, and recycling systems) LU 0 1 2. 3. q, 17103 20. Designated Facility Owner or Operator. Certification of receipt of hazw'dous materials covered by the manifest except as nded in Item 18a Printhdifyped Name r� mature Month Day Year Aft; 4a 1 121 EPA Form 87&22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e- MANIFEST SYSTEM