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Please print or type. Fnrm Annrn nd nMR Nn qmn-nnia <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERAT R'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emgrency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />! <br />A. 1800-- I <br />JJK <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />?f~SOURCE P,K.:f,:OVERY SERVICES <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />1 <br />:iVF RY SFRVTCE S <br />3:L50 %"AsST (.l C0 BLV0 <br />I.0S AN G E. 1. E `:i, CA 9002 <br />Facility's Phone: (800) 499-711:? <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1-0N! l:ay 1AA STl`" FL,AtiIyJABLE S0L1..DS, [iRGANTC, il.,d,)o'; <br />O�A(.1F..COINE., <br />, 4,1, PG11, R {.(0, <br />sb2 <br />I <br />4)011 <br />f' <br />w <br />24,11:01_'3 1, Wt�ti�'�E. AI`:ISOSO11.S, 2 1. <br />i <br />?:l.4 <br />L <br />3. pit F(A HAZARDOUS 4.JAST S3C)i..:Ct;) (E3OW.10 (W) <br />3'it <br />IWASTL 1i.�IJ L' (i-.tr; i E�;ESt Ni:. <br />CLk:�VNiN S(Sl.f.JT11 N) (CAI..,J.i=(.Rl'4'1A REGUL'.F1(ED <br />- <br />ONLY) <br />0M <br />14. Special Handling Instructions and Additional Information <br />�9be-- ,) Fifa # (5 4(W) <br />GLOVf_'S, !xQGQLES & WROTECTWE CI.OTFi: NG- 24HR F'.MFF{(:ENCY I:;ONTAt;:Tt KIRK WIAI.f)ti)R <br />ERG * 9b1,1133 9br- ; 12690 )BONE- 9h4, , daCkNE <br />S Al"!Cii'+0r » r .t I>t:`.1:D)�E !� L ai?:iiZ . 2.1 ,4..1,'; <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are <br />classified, packaged, <br />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 a <br />d 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) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature <br />Month Day Year <br />.j <br />F- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port <br />z <br />of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17, Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature <br />Month Day Year <br />O <br />a <br />z <br />Transporter 2 Printed/Typed Name Signature <br />Month Day Year <br />h <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type ❑Residue ❑Partial Rejection <br />❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. <br />4. <br />ated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />ed Name Signature <br />r9i <br />Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERAT R'S INITIAL COPY <br />