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5K SiHIP# Please pn pe, >'i� t�•1,,"I, , Form Approved,OMB No.2050-0039 r..a, UNIFORM HAZARDOUS1'.Generator ID Number 2.Pada 1 of .Er�etggn Res nse Phone• 4.Manifest TrackingN Number WASTE MANIFEST CAP.�+e03`9,a r Kr jti Wil ' i 4:k (�t ` .e. �Fy SKS S.Generator's Name and Mailing Address Generators Site Address Of different than mailing address) i9b5 kznenry AVL- CA 55--3120-0000 Generators Phone: 209-3m—"31 1 6Jransporter,l Company Name, U.S.EPA ID Number SYSTEM INC 7.Tran2 Company Name U.S.EPA ID Number =� FiAHBJRS ENV SVC INC. 8.Designated Facility Name and Site Address �;LEA-�y1N HARBORS ENtiNV I�tUNMENVTIP L SERV I CU s IN,' U.S.EPA ID Number KIMBALL WE 691451- ra�C�9i723�i3 Facility's Phone: 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. 1 T tF'%dC4_ �N, US, TOn f Z O N 0 (P{APt T 'A LU z. c� 3. 4. 14.Special Handling Instructions and Additional Information i SSD k KP e, . , r agenC +�'uzhap_ r.,t�,.E,�ta �, g��1..r��.,�r- �u ��:r�� , 93� % alftrl Q1?' YtSi 1G 2( ;.i�t 20-2•?? QF,ai t�-�AnsDar i:i�'rt£'t"��t♦'.'y _ L"r$Nt w E T 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 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 I am a large quantity generator)or(b)(if l am a small quantity generator)is true. renenator's/Offerors Printed/Typed Name Signpre Month Day Year _j 1 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrytexit: 2 Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials UJ Trahsporter 1 Printed/Typed tame Signature ; } Month Day Year 00 z Transporter 2 PrintedfTyped Name Signe re Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑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 v5 19.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 Printed/Typed Name Signature Month Day Year EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY