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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.M rf t T cId g umber WASTE MANIFEST CAI? 9 8 1 4 fs 6 5 8 4 _ �+t}r �d� �3JL , .l 8089 FLE 5.Generator's Name and Mailing Address Generators Site Addspss Efferent than mailing address) '--Eleven, inn- —EYEtt/0/1 20 a,4621 DA VINCl DRIVF[ Box 90741 Iq fix Rancho Santa Margarita, CA. 3-4688 )CKIMN CIL 952017 Generators Phone: 7$49 i 6.Transporter 1 Company Name U.S.EPA ID Number n p 3913 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number World 0i fiveve] ing CAT0" 91) 013352 outpton, CA 90222 Facility's Phone: ;J J cl' 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. 1. �f%:.s3 GaL'•2.in.eix�ut e. 3, PG 11 CK 1 y LU i z 2 t.0 [7 a. 14 Spedal Handling Instructions and Additioral Information WEAR ALL Af f ROE T&TL viAeclj.na a wat •4r 7-11 CSN: 613710 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I cedify 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)(ifl am a small quantity generator)is true. Generator'slOfferors Printed/Typed Name Signature Month Day Year J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Dale leaving U.S. W 17.Transporter Acknowledgment of Receipt of Materials LLJ Transporter 1 PgrtedlTyped Name Signature Month Day Year CL Z Transporter 2 Printerittcl Name Signature Month Day Year GC H 18.Discrepancy 18a.Discrepancy Indication Space b ❑Type ❑ ❑ I ❑Fufl Re' ❑ Quantity Residue PaRialRe�dion lection Manifest Reference Number: 18b,AltematerFscility(or Generator) US.EPA ID Number J U Facility's Phone, W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes far 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 Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY