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Please print or type. <br /> I� <br /> UNIFORM HAIAR6pU5 2.Page 1 of ,3.Emergency Response Phone 4. Form Approved•OMB No.2050-0039 0039 <br /> - ZZ1 9180 JJKWASTE MANIFEST <br /> 5,Generator's Name and Mailing Address Generator s SifeAddress(it different than mailing address) <br /> ANCIRWAN Ct15TO1uf Mt-kT <br /> 4277D N TRACY VL\.Ao <br /> Tp-kcY,CA 953U4 <br /> Generator's Phone; <br /> 6-Transporter 1 Company Name U.S.EPA IQ Number <br /> G@Gf(18 W. Wwfl<,IGC- vJ470,- <br /> 7.Transporter 2 Company Name U.S.EPA IQ Number <br /> &Designated Facility Name and Site Address <br /> U5 ectLwk S.U. FAA ID Number <br /> swV '9$ 11li1"6 S'tO'r of�.E�' Fr fV'4�3Ai1ft7L�?r <br /> BATTY.M, 89DD3 <br /> Fadlity's Phone:7154P5- 3 <br /> ga• 9b.U.S.DOT Descxfption[including Proper sNpong Name,Hazard Class,ID Number, 10.Containers 11.Tata! 12.Unit <br /> HM and Packing Group(if any)] 13-Waste Codes <br /> No, Type Quantity Wt.fVvl. <br /> �T4t Bi <br /> ry <br /> 2. <br /> 3. <br /> C <br /> 14,Special Handling InstrucGvns and Additional Information <br /> E <br /> USE!GL ,J - <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:!hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and lebelerVacarded,and are in all respects in proper condition for transport according to applicable intemationatand national governmental regulations.If export shipment and I am the Primary <br /> Exporter,f certify that the contents of this ronsignmerd conform to the terms of the a!tached E"AAcknowfedgmem of Consen#- <br /> I certify that the waste min rization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if!am a small quanfify generator)is true. <br /> Generatarslofferors Pr'nledlTyped Name Signature Month Day Year <br /> Ll <br /> l . r <br /> ri(I <br /> „j 16.International Shipments ° <br /> �- ElImport to U.S. ❑Export from U.S.- Port of entrylexit; <br /> 2 Transporter signature(for exports only): date leaving U.S.: <br /> fK w 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Transporter 3 Pdnte yged Name Signature Month pay-7-01 <br /> r m� - a <br /> Transporter 2 PrintedlTyped blame Signature Month day Year <br /> 18.Discrepancy }} <br /> 188.Discrepancy Indication Space ❑ Quandt) LJ Type ❑Residue u Partial Rejection <br /> ❑Full RejecEivn <br /> Manifest Refere <br /> 18b.Alternate Facility(or Generator) nce Number: <br /> U.S.EPA lD Number <br /> v <br /> LL Facilitys Phone; <br /> [ 180.Signature of Alteni`ate Facility(or Generator) Month Day Year <br /> 4 <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> C! 1' 2• 3. <br /> 4- <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by tate manifest except as noted in Item 18a <br /> Printsdfryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />