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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 1 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Geremtor ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST INLIIXV-3 `lS A) G B Fi _ ' S.Generator's Name and Mailing Address Generators Site Address lif different than mailing address) v\i- 'LNr. CA�26U 1N�. -y 1000 W, 0- WA\/ Generators Phlor�'ie: ��- � -C`-\ Oat A St 0(C 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address US EPA ID Number Facility's Phone: ga 90.U.S.DOT Description(Including Proper Shipping Name,Hazard Class.ID Number, 10.Coral am 11.Total 12.Unit HM and Pi Group(dant')) No. Type Quantity WtNd. 13.Waste Caries 0: 3 14 Special Handring Instructions and Additional Information 15. GENERATOR'SrOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described shove by the proper shipping name,and are classified,packaged, marked and Iabelediplamirded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If exportshipment antl I am the Primary Exporter,I certly that the contents of this consignment conform to the lamas of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 261(8I am a large quantity generator)or(b)(dl am a small quantity genembin is We. ratorslOgerors Printed/Typed Name Slgnabxe Month Day Year k _ui 16.International Shipments 1= ❑Import to US, ❑Export from LLS. Pod of entrylexit, Z Transporter signature(for exports only): Date leaving U.S, C 17.TransporerAdmowledgmet of Receipt of Material Transpoder1 Printed/Typed Name Signature Month Day Year H S a•� M A u,t-) Q Transporter 2 PdntedfTyped Name Signature Month Day Year i18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fall Rated, Manifest Reference Number: 18b.Alternate Fatuity(or Generator) U.S.EPA ID Number E3 V LL Faa3ilys Phone: W 18c.SIgnaturs of Alternate Facility(or Generator) Month Day Year a z y19.Hazardous Waste Report Management Method Codes(le codes for hazardous waste treatment,disposal,and recycling systems) � 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Cerification of receipt of hazardous materials covered by the manifest except as noted in Item 18a II♦I Prinlecirfyped New Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY