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Please print or type. (Form designed for use on elite (12 -pitch) voewriter.) Form ADDroved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1 • Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number G B F WASTE MANIFESTt', Cifer3 �,j 1 i L. 1 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) RAG QTY %'I 0a21 CAll Tit. aVt L(1nil,. CA �!i) 1.4 Generator's Phone:209-4101 81Ci 6. Transporter 1 Company Name U.S. EPA ID Number :tea H"' WS SOL.f 1104 6. IK CALU-40MU97 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address a U.S. EPA ID Number l'a,��Nt1��> t•.t'�1�1�;3'� a, l � . .i: �1stlt"°1•iC.! t.�f�`1;}t�1f7'o, �:rd1 �k`.±t(�}:,' Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11, Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. r+WAtiSJ I -z: F At 10, fj f i :; . 0, fs1A3017,111 00111 o (f1EINZIHEI.CAI VAS JK') IES 1 6) ---} - r Q w z w 2. ----- 3. 4. 14. Special Handling Instructions and Additional Information i 4.(~ kv",1 ' r+l F+VW 11'11 HES R t -L )•h'. )S S k P1 14 t,'•,.IliRATf. l i .. ( L4,. I iv ;, LO T141464 [t F:K3 #171 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, 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 I am a small quantity generator) is true. Generator'slOfferor's PrintedlTyped Name Signature Month Day Year c i \ ti .r ;_..� � •,�:r �.i ... r> '..� ..,i'[„! fr ,; ❑ Import U.S. Export from U.S. Porto entry•'exit. 11 H Z to Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year a �} ) co Transporter PrihtedrPypedoNamel Signajwe ,,"4, Moritr y jY 1rJ 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_ 0 LL Facility's Phone: W 18c. Signature of Altemate Facility (or Generator) Month Day Year z Ca 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. Notice: New federal form. State of Califomia requires generator to photocopy 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 186 and mail to DTSC within 30 days: Pdntedrryped Name Signature P.O. Box 400, Sacramento, CA 95812-0400 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY