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Please print or type. Form Approved, OMB No. 2050039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number WASTE MANIFEST I Cs/ IiNA 24CL06 20�+ *394110 1 019676941JJ K 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) �7: O tF?!'•}a T ':Pf Tfii:P0F,CA IW0,4` �:.t; 7 Generators Phone: 2�'"2 6. Transporter 1 Company Name U.S. EPA ID Number eq4erJIqe wt IJI)Nry01C, E_ 7. Transporter 2 Company Name U.S. EPA ID Number l 8. Desi n ted Facili Name and 8t Address U.S. EPA ID Number �. �".f�ee'yy01L IR�'(aYt.LAfN} 4ftr 1 _'. ; ( J. � fd Ave, i-t i+.l�tq.t'mR , 40OR ;i „tiedtri. Facility's ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Totai 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes a X 1 ' €�1t&I h'CRA, HAA UX)11Z fVmf%TES i��it ? i;lAF t (rg3 i4 Cil i tar.,) �}kI r t P O r { 2. w 0 3, 4. 3N ' AR 0 2019 14. Special Handling Instructions and Additional Information ENVIRONMENTAL HEALTH ALL TH DEPART 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) (ffl am a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year ry : 16. International Shipments a V ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAckno�ledgment of Receipt of Materials /W Transporter 1 Printedrryped Name Signature f Month Day Year ZTransporter 2 Printed/Typed Name Signature ' Month Day Year 9 18, Discrepancy 18a, Discrepancy Indication Space ❑ QuantityEl yp j j Type Residue Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U .S. EPA ID Number J Facility's Phone: Lo 18c. Signature of Alternate Facility (or Generator) Month Day Year B 2 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1 . 2. 3. 4, 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printedfryped Name Signature Month Day Year EPA Form 87022 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY