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Please priht or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator If]Dumber 2.Page 1 of 3.Emergency response Phone 4.M(annNest Tracking Number 1[ WASTE MANIFEST .:ri k.#i#11}. : !i:i f(f - ,a.�tj s 3 3tt s.J 2 011612 5 J J n Generators Name and Mailing Add" l: tr f3f 4 t:tC7fT1.f GerteratofsSipaAdtfress 9different than It address} ,)boo f.ma's kaa(i t*J4 '3 i a}h�+x3 i'/ 1hfk fit! Ee Generators Phone; 6.Transporter 1 Company Nam UIS_EPA Ip_Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Faollfty Name and Site Address U-S.EPA If]Number I1��11et1i0 ,et iaa�t t.;ofr1#r on,i::,A, 90222--2f0V USA Facffity's Phone: 98. 9b.U.S.DOT Descrfptlon(including Proper Shipping Name,Hazard Class,ID Number, 10.CoYrtainers it.7ntal 12.Ork 13.Waste Godes HM and Packing Group lit any)) ft Type Quantity vvuvbi � 1'Aunt •Is:#y�,�rfg��"�fr-�!�,�-n'� i�tfd�'1 13d tR,°$ PC It ERG#I Its � u.r z 2 ' LU C9 3. 4. f �..Sper9 l land! instrrpctgryrs a d Addltlonal Information s�SCr �. . ve-"'. �.E1, Wear APOOMate t:k*iInCif ire"'9tw 15. GEN ERATOR'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 labeledlplacerded,and are in aH respects in proper condition for transport acconiing to applicable international and national governmental regulations-If export shipment and I.am the Primary Exporter,I certify that the�cntents of this consignment conform to the terms of the attarkred-EPAAcknvwledgmedckf Conant. I certify that the to n7nhnizadon statement identified In 40 CFR 28227(a)(if f am a large quantity generator)or(b)(fffAT a smelt quantgpnemlor}-tsiffi. t Gleno atorslOtferor s prin yped Nae S gnature- Month Day Year � lntematio i eats - - �, - ❑lmport!to U.S. ❑Exportomtl h .S-_ Port of antry)exif: Transpo signature(for exports only): Date leaving U.S.: ad 17.TramporterAcknowledgment of Romot of Materials ransporter f PrintedlTypedame Signature Month Day Year aIL aTransporter 2 PrirdedfFyped Name Signature _ Month Day Year 18,Discrepancy 18a,Discrepancy Indication Space ❑ 0"tity ❑Type ❑Residue ❑Portia!R011tion ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility{or Generator} U-S.EPA ID Number U rQi Facility's Phone: . w 18c.Signature of Alternate Fac011y or Generator) Month Day Yaar a Y .Hazardous Waste Rsport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3- J4, 20.Designated Facility Omw or Operator:Cerlikatlon of receipt of hazardous materials covered by the manifest except as need in fterriiaa PrintedrT ped ijame Signafsuey ° Month rDay Year ,-• •^ ��c r•. � lit f ,•! � f" '� ��` L EPA f=orm 8700-22(Rev.1217) Pravlous edltl6ns are obsolete. TRANSPORTER COPY _,