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print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 INIFORr EODUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) .kxktzis CA 962- l it r sy_4,'a ypk} Generator's Phone:,, •�` '•-�••`0" 7� 6 Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number x : l J I • Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. O � fy 4 Z 2 A 4 X&sm Uqdd W C� t 3. s' I 4. 14.Special Handling Instructions and Additional Information21 ACIM480 1144:= 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 EPA Acknowledgment 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'sPrinted/Typed Name Signature, Month gay Year -J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transported Printed/Typed Name Signature Month Day Year CL U) Transporter 2 Printed/Typed Name Signature I Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: F 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Q LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Cndes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR