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ease print or type. Form Approved. OMB No. 2050.0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number �+ WASTE MANIFEST C A. 1, 0 0 0 3 7 6 8 0 6 1 (Si7) RI SAA ft7 VES 0 01.5 2 0 2 3 3 YES 5. Generators Name and Mailing Address p.A.CTTV 1'An(A%#D* 1.L r t4Ct1 ASI I41! Generator's Site Address (if different than mailing address) PA,fC CIV P�d��C" GT"!y£�IN 31W, 1111/0TT�/6`�fi�i�k.�t'��(P/.l�l�+S/t+�TCryS r)R/y� fl ; QANTAS LN S d l✓L.K ON,, CA. .^5700)'492-5 . p4.` �., tT L OCK L OH, 4. A Z'206.3902 Generator's Phone: 2013 Z3.-1930 6, Transporter 1 Company Name U.S. EPA ID Number "Y%`r'tL AL fay 3 rY-7"'11MCAL SOLUTICM N 3 Ti 0 a 0 6 i 1 3 6 9 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address 1VIA FS TIsOMICA L ,lii:I S, U.S. EPA 10 Number L.L.C. 1704 W. FHW ST'P= AZLISAti, :':.r. 91102 Ce _n 0 c1 S 3 {i 2 P i1 Facility's Phone: �? i 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity W4Nol, Y- 2: z 2. L 3. e......- rt;.. �., 10V 2018 4. EN IRO - 14. Special Handling Instructions and Additional Information a ,9l owirfiaed by tlM$ {Vagd; fah +an za�r t3rttrt isii#iat txae tr i #� �4c3ot i #tui+4 zx itdstioo->l�l #arcte> a�tt �l zt'.gt rlf -I- 1) W, 3tIC AAAA- ITCiT.3r!f�'C�S 15. GENERATOR'SfOFFEROR'S CERTIFICATION: 4.ereby 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 am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attachedEPAAcltnowledgment 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) (d I am a small qu ntity generator) is true. Gener-a}ttots/Offerors Pnnte /Typed Name Signature t Month Day Year J 16. International Shipments ❑ Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials tr r Ira porter 1 Printedlfyped N e Signature Month Day Year Z Transporters Printed/Typed'Name `y Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ElQuantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J L Facility's Phone: L 18c. Signature of Altemate Facility (or Generator) Month Day Year Q Z D19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LJ 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year PA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GtNtKA I UK'S NMAL IAL C;UNY