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I tV00. Form Approved. OMB No. 2050-0039 4 GENERATOR ). UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number A 1.) i.; . 'I 4 2. Pap 1 of 1 3. Emergency Response Phone 4. Manifest Tracking Number ' i 20 JJK 5. Generators Name. and Mailing Address Generators Site Address (if different than maihng address) . '---ik,N FPANCISC.0 CA 90120 WelOKY01,1 CIA isti,,if,* ,-; a 0 7 6 I - 6 0 0 0 I Generators Phone: Transporter 1 Company Name U.S. EPA ID Number , , ; r ' 0401.1!,,:i RI.tkl OUTSOURCING, 1.P I - 0 0 2 0 0 5 4 Transporter 2 Company Name U.S. EPA ID Number I Facilites Defirlltd(Ffilltypilgre and Site Address U.S. EPA ID Number FIVW 95 I NI • 01- 1-..t: A 1 I , pr- ,\T-i'v NV now. Phone: 6f1 T ' I NVT130010 l' 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. blaate Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. , i l:'!k:7ARDC.)08 1.'1k: '. , SOI.in (011.v SounTh 14. Special Handling Instructions and Additional Information I i..)1.1 1 1 1 rpov r 1 'f, P. J , 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if tam a large quantity generator) or (b) (ill am a small quantity generator) is true. Generators/Offerors Printed/Typed Name ,,, , • c ..„/i. ,. 1 Signature Month Day Year 5' I III _i 16. International Shipments Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only) Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year ., ..'1.1-. 1 )-C ,,,Iiiuli k I ,,/- i I . I . Transporter 2 Printed/Typed Name Signature Month Day Year I I I I 4----- DESIGNATED FACILITY 18. Discrepancy Discrepancy Indication Space LII Quantity Type LII Residue El Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Rem 1Ba Printed/Typed Name Signature Month Day Year I I I I GENERATOR'S INITIAL COPY EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.