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d Form Approved . OMB No. 2050.0039 Please print or type, (Form designed for use on elite (12-pitch) typewriter.) r 1 . Generator ID Number 2, Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number UNIFORM HAZARDOUS t z r ; . t X111 GBF WASTE MANIFEST l > ;r ; ; i 5. Generator s Name and Mailing Address Generator's Site Address (if different than mailing address) are. . t 3 l 5 Generators Phone: '-111 WIN I 1 1111 11111111 111 111111111111 U,S. EPA ID Number 6. Transporter 1 Company Name t i MAR 0-w2 2nIG U.S. EPA ID Number i 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address . t. U.S. EPA ID Number NVIRON ? ,: . � ) 1 �Q 'YPV� h1T h ' r• IL WINI Facility's Phone: 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes 9a. No. I Type Quantity . Wt.Nol. HM and Packing Group (if any)) IL Ce W 2 — -- � �3 c 3. VI 4. I} 14, Special Handling Instructions and Additional Information IIx {:i - i 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 intemahonal 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 EPAAcknowiedgment of Consent. iL 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. MIN Generator's/Offeror's Printed/Typed Name Signature Month Day Year II - i' r � 16. International Shipments ❑ Export from U.S. Port of entrylexit: W . ❑ Import to U.S, Transporter signature (for exports only): Date leaving U .S.: i w17. Transporter Acknowledgment of Receipt of Materials ti Signature Month Day Year •Transporter 1 Printed/Typed Name # .N O. > , y,• i s in Signature Month Day Year a Transporter 2 Printed/ryped Name cc I " 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number V , W Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a z N 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) Notice : State of California requires es 0 1 . z. 3 generator to photocopy and mail to DTSC within 30 days : 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Iter P . O . Box 400, Sacramento, CA 95812,1 rar Printed/Typed Name Signature EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY