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Ffease t ILII or lyp �. conn Approved.0M6 No.2050-0039 r r p a} n n, Rr t-Gnemlor ID Number 2 P_ge I of 3.Emergent}Resporrs Pnona6 5.Generator's NamAddress and Malling Add _—"— — I Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name f' U.S.EPA ID Plumber 7.Transporter 2 Company Name U.S.EPA ID Number' 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone;, t I ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers $�11.Total 12,Unit HM r and Packing Group(if any)) t l 3 ( 13.Waste Codes I 4 — -- — No. r Type I Quantity Wt./Vol. f t gz. 3. 4. 14.Special Handling Instructions and Additional Information .., , 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 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!` i r 16.International Shipments ti El Import to U.S. ❑Export from U.S. J , Port of entry/exit:R Transporter signature(for exports only): Date leaving U.S.: � 17.TransporterAcknowledgment of Receipt of Materials Transporter1Prnfed[rypedName r � Signature L> Month Day r. Year M Tran�porteF2 Printed/ryped Name Signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Reference Number: 18b.Alternate Facility(or Generator) Manifest U.S.EPA ID Number _J i Facility's Phone: IBe.Signature of Alternate Facility(or Generator) Mdnfh `''Day Year 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 generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days: Printed/Typed Name Signature P,o Box 400 Sacramento, CIA 95-812-9400 'A Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY