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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.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST t 013304836 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 190 REM WbM iStoddtnn, CA 952DB Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Aid CheMICA TrWapcd b-rlD13A ACTen%iM CAIIOOOU70540 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Hwbw i of Sets J=A LLC IOZ Bexryes al Rod CA00694Q4310 Sm Jose, CA 95133 Facility's Phone: 40844i2 9a. 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. O X 1. Q,UNI993,Waste Flmtl mud le hilittids,>tt.a.s.. 'ROLEUIMI P 217 W01 FOW rxs WS,XYLEMs),3.P�PPI) J �' F006 Z 2. W C9 3. 4. 14.Special Handling Instructions and Additional Information "•7ad Mnbff 2MO ICS t WMW 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 labeledlplacarded,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 EPA Acknowledgment of Consent. " certify that the wastTminimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a smfll quantity generato'is true. Generators/Offeror$,frr Med/Typed Name y Signature d f Month Day Year 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU FZ; Transporter 1,Printed/Typed Name Signature Month Day Year a ZTransporter 2 Printed(ryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type yp ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL Cc