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Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 14,klanife t Ti cki g Number,- <br /> JJ� <br /> WASTE MANIFEST C.14 )3%B t6 a� , 4-16W 0 <br /> 5.Generator's Name and Mailing Address Generator's Sfte Address(if different than mailing address) <br /> NCILt.,5+O RV+WES CO. UX <br /> 1780 fit# USTIRIAL Dr. <br /> CKTON,CA 9 <br /> Generators Phone: . <br /> 6.Transporter��I Company Name U.S.EPA <br /> �JDpN uu ymbber+��x�y <br /> �eol"wit. f,Ino. C/'iC�w�OU4 019 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA 1D Number <br /> 1J4iZrkx� <br /> MVVY 9 1111086 SOUIP of 5EATTY <br /> TTY,KV es <br /> Facifity's Phone: 775-5$3-22D3 <br /> 9a. <br /> 755- 3- <br /> 9a. 9b U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(ff any)) No. Type Quantity 12. ol. 13.Waste Codes <br /> f' no U fN 19W V AISTE A!ROSOLS ' c { r✓ <br /> w <br /> rZ 2. <br /> C7 ' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PF OFkE1# USI!CLOVES IA}ry".'rtC <br /> fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are . <br /> marked and labelsdlplacarded,and are m all respects m proper condition for transport according to applicable intemationaland national govemmentaf regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Generato(slOfferor's Printed/Typed NameSignature Month Day Year <br /> f <br /> ,,,j 16 International Shipments <br /> F ❑Import to U-S. '. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U. <br /> W 17.TransporterAcknowWedgment of Receipt of Materials <br /> LU <br /> E2 Transporter 1 PdntedlTyr*d Name. SignatureQ;7T Month Day Year <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b Alternate Manifest Reference Number:Fac lity{or Generator} U.S.EPA ID Number <br /> J_ <br /> C? <br /> Facility's Phone: <br /> W 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W <br /> p 1 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator.Cartitication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prinled/Typed Name Signature Month DayYear <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />