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I'llease,pith it or type. For!n Approved.OMB No.2050-0039 y -rn-t?ncy Respons3 Phonl- 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone:, . 6.Transporter 1 Compny Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.FPA ID Number' Facility's Phone:, 9a. 91b.U.S.DOT'Descriiption(including ProperShippirig Name,Hazard Class,ID Number, to,Containers 11.Total I Packing Group(if any)) I HM and 12,Unit 13 Waste Codes No. Quantity Wt./Vol. Type -lanfily 0 3. 4. 14.Special Handling Instructions and Additional Information 1. :,';-, : , -,- lu 15. GENERATOI;VSIOFFEROR'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 th6Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I I codify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if]am a small quantity generator)is true. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year -j 16.International Shipments ❑Import to U.S. El Export from U.S.. of entsylexit: Transporter signature(for exports only): Date leaving U.S.: q: 17.TranspoderAcknowledgment of Receipt of Materials LU 0� Transporter 1,Printed[Typod Name Month Day Year LL m Trar ,#oitet2 WintediTyped NRe Signature Month . 9Year f 18.Discrepancy I— I 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue E]PaM.1 Rejection ❑Full Rejection -18b.Alternate Facility(or Generator) Manifest Reference Number: Zi U.S.EPA ID Number Facility's Phone: Lu 18c.Signature ofAlternate Facility(or Generator) Month Day Year !R- 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1, 2. 3. Notice: State of California requires I generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous'inaterials covered by the manifest except as noted In—Item 18, ©TSC with 30 days: Printedqyped Name Signature --R 0 Box 400 sacre.tile nto, 95812-0400 .PA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY