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Please print or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emefg5 Response Phone 4.Manifest Tracking Number t MAST1EN1 NIFEST €", I 7�1��s7tC�S�� $ PP$"" 800 4Y--)--71 45022258660 V J K ° 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ACUSA Chi IF, DBA ADE-90 GOLDEN GTE 0501 I S1ANFORD REQ Generator's Phone: 21213 44A- 6. A 6.Transporter 1 Company Name U.S.EPA ID Number PACIFIC KF'MURCE RECOVERY SERVICES 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number PACIFIC RESIDURCE RECOVERY SHVICES LO IJI:�I^L ES, CGS f 3 Facility's Phone: (8100) 49q-7145 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. fib. 1`� ,d Ie_ I it Y9 W4 I ,. . w 4: z t F! a` L} La 's : �- rli I $ R ' ' Ir 0 1 1,;'? . . tinTr"R IAL 3'I gt4 Y'ZCRA HAZARDOUS WASTE: LIQUID 133 MATERBORNE CLEANING 901. T ION) 4. 14.Special Handling Instructions and Additional Information R S%!111,3132 GLOVES, PROTEC I'I M CL13TIA i NG 24HR EMERGENCY +COM IIM K I RV WrAM)RF 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 EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262,27(?)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. ne atoes/Offeror's Printedlryped Name i Nature MontfJ Day Year 16.International Shipments ❑Import to U.S. El Export from U.S. Port of entry'lexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of MaterialsLLJ r' Transporter 1 Pdnted/Typed Nome f Signature } fs ' Mont)r Day. Year r'rFstr. > e if , 16' Z Transporter 2 Printed/Typed Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial Re ❑Full ❑Residue Rejection Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U ra Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year Q z 0519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. a 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdntedrryped Name Signature Month Day " Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY