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Please print or type. (Form designed for use on elite ( 12-pitch) typewriter*) Form Approved . OMB No. 2050-0039 UNIFORM HAZARDOUS 1 • Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number e e t WASTE MANIFEST Oilf LC r"' iii "' �" .a� ' t �r �q 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) NoWn Bouhteg L .. e 811 - PtTyr t'l aoc CA 052M nerat s hone: , 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 ompany Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number cod CK-mical ImAment 6133 h Abcx1jer9m), tf Facility's Phone: Vj5mv. ra `y 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt A/ol. 13. Waste Codes O RQ, r, f csPrA, 1 00355 F0013 343 w z 2. r . W 1 r f .: r ` � H � ° ' i � ; � �., : t t • �,: r `r � ` - � t . ' , � - � � . 3. t 4. 14. Special Handling Instructions and Additional Information p1ble "1,. 1 . Docf 7 128; ACT3574 , L . , i . f f = 15. 6ENERATOR'S10FFEROR'3 CERTIFICATION: I hereby declare that the contents of this consign ent are ful y and accurately described above by the proper shipping name, and are classified, packaged, marked and abeled/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 EPAAckno;rrtedgment 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. Generatoes!Offeroes Printedtfyped Name Signature Month Day Year �j 16. International Shipments F— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (far exports only): Date leaving U.S. : W 17. TransporterAckmMedgment of Receipt of Materials ° Tri sponer i PrinCr tedTf Jame ) Signature Year Month ay 4 CL M th Da Year z Transporter Printed(Typed Name —r r Signature Y 18, Discrepancy 180 . Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Facilit 's Phone: U t8c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19, Hazardous Waste Report Management Method Codes (i.e ., codes for hazard s waste treatment, disposal, and recycling systems) C 4 . 1 m. 2. 20. Designated Faci ity'Cnvner orOperator. Certification of re pt of hazardous materials covered by the manifest,exce$t eoted in Item d8a- -. __ _ , _ Printedflype ame Signature Month �r Dayr Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERAT P