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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 el WASTE MANIFEST , : r Ile i ,�, ij {, G B F r ! r, % 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) ;Ir11t: JI4I)0I ; iiitel : t `• ; � Idt) tt �i't : s = : 1 r•. �1 <, ;t ;� ! :>' tFila _ , let Generalces Phone: ' i : . . : i 1 %fi Be Transporter 1 Company Name U.S. EPA ID Number • ',t't( r. fill :.`i' 1 'i1r=• t1 ( , . ': i : X11 ' . . i � . . . i. :PIi .ti0 lei { ; i •' I �I 7. Transporter 2 Company Name U.S. EPA ID Number • . , : fili; YCa ,Fi ':it' EiCfP,t fY lr`JF� .`Sif•: :ii )!_ lC; l(::f4.;. U''Jt : R,'1rd , ' :i;J' l i i ; ) r;�'. l Be Designated Facility Name and Site Address U.S. EPA ID Number . . Cl t i. i1 ( iP ,' i � I' e'Vtt t)i �. :it: f'dfFit i ,1i::%it �. ! I fSl. dr .l:?'`•. . t . L.-. Facility's Phone: ga. 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)) Ni . Type Quantity Wt.Nol, 13. Waste Codes ' / ' . � li' W 2. J 3. 4. 14, Special Handling Instructions and Additional Information Pica?itis. ; ' ; 'r;i14� •J ill) V•w+41t . S( iLUti. t. ti �:f# f7t 1G: Ia3t .I :C ' t;r:atfi:,i : I VVI 1. IAfviNi'tt%44Ai r 15. GENERATOR'S10FFEROR'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 Iranspori 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 EPA Acknowledgment 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) (•dl am a small quantity generator) is true. Generators/Offerors Printed/Typed NameSignature Month - Day Year . j 16. International Shipments F— ❑ Import to U.S. ❑ Export from U.S. Pon of entry/exit: z Transporter signature (for exports only): Dale leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials Transposer 1 Printed/Typed Name Signature Month Day Year, a rn Q Transporter 2 PrinledTlyped Name Signature Month Day Year E- 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity [I Type ❑ Residue Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U LL FacilitysPhone: w 18c. Signature of Altemale Facility (or Generator) Month Day Year Q Z IT19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyding systems) 0 1 . 2. r ) I777 Notice : State of California requires generator to photocopy and mail to DTSC 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a within 30 days : Printed/Typed Name Signature P . 0 Box 400, Sacimamento, CA 95812 -0400 EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR ' S INITIAL COPY