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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.Manifest Tracking Number � a WASTE MANIFEST t u' r . ` , - .h 4 VL01i 4�, JJK 5.Generator's Name and MaSSilirg Addroiss Generator's Site Address(if different than mailing address) f � Irl s-€ �y k � t - •- Generators Phone: 6.Transporter 1 Company Name U S.EPA ID Number i ANIOS F-F+Es K''0?dM i%ffA.tw 111K, ,_. . . .-...... 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number R.•��J1$,�!;L1VtARC3P$Itr}E�tT�.:sERL;qCEfia. lid, CA ?44eT 111515 tiOM MVER R0. - i f SACF A1JF-- lT0,CA 95691 Facility's Phone.91&1371`f 47 Ra. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tota! 12,Unit 13.Waste Cades HM and Packing Group(if any)) No. Type Quantity Wt ivol. 1. F QF4 F CKA HAZARMLIS'dtj,ASTE LlMID (OILY !}t`ER) �. � 223 Z 2. UJ _. 0 3. 4. 14.Special Handling Instructions and Additional information HANDLERS 10 BE'TRMFI !'J?F40 tJ!;E A PIRIC )ED PPE. � 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratAdescribed above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition fartransport according to appiicable internationaJ46d.national governmental regulations.If expott shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Coll nt. I certify that the waste minimization statement identified in 40 CFR 292.27(a)(if I am a large quantity generator)or(h)(if I am a'small quantity generator)is true. a `GeneratorslOffSinature Month Daeror's PrintedlTyped Name 9 f` � r, c� r a,Ye_, 16.International Shipments F d Port of entrylex❑Impart to U.S. ❑Export from U.S. . t: Transporter signature(for exports only): Date leaving U.S.: W 17.TransponerAcknowledgment of Receipt of Materials LLI Transporter 1 Prirtedffyped Name Signature r' Month Day; Year Z Transporter 2 PrintedlTyped Name ' Signature '' �' Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 1}- 18b,Alternate Facility(or Generator) U.S.EPA ID Number J_ 0 LL Facili y's Phone: w 18c.Signature of Altemato Facility(or Generator) Month Day Year Q z An19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1. 2. 3. A. 20.Designated Facil ty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolele. GENERATOR'S INITIAL COPY