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Please print or type. Form Approved,OMB No.2050-0039 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM MANIFEHAZARDOUS JJ WASTE MANIFEST t'Ri-rStt(13:3:.3[i4a e 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) i)IE.L)f-(10NSi RIXII KA I, I I (). 1 11(XJ I 123£+1:3 N H*PJVAY 49 ilK)UL7HK4LJUk: t.,A 3')E0 Generator's Phone: '3-;itt`�-Lia'.:]::� I.0(11.(`A A5740 6.Transporter 1 Company Name U.S.EPA ID Number AW--, t1(,At4 VALLE1r WAtiff-(DH-"IM, GAKi)iIul 7.Transporter 2 Company Name U.S.EPA ID Number t;Li-.AIV t-.�Fdltl i}IHULiLiilLJ11(lfil:?e 6.Designated Facility Name and Site Address U.S.FPA ID Number �i:i1 E;i�1+JtiltdY!•.f�iliiJi51AAFN1At. tlltvl�9i t)1 NI.1>rFniat�,kls; i1'J1°7#Afit1,9€a53;1R i'IRt-ILf y,fv"v 31,: Oil Facility's Phone: 2/W 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./Vol. 1' c I.)(1(11 13UiJ13 1€11 o Ftp IVt1:;f?.77,F1A7AF7[1f (1 tdti4A`,TF 5t7l.ICl, hJf7 ,1 , .., X1111,I F.Agl' tat L: 0 fi IRCh'uiltJfsll Z 2. w O 3. a 14.Special Handling Instructions and Additional Information I'RC&ILL Itd11'(!>`-(AJ 1*1- 11f_ ;i11PVif'4'6Zi a 1! 1 EWIE€tGEiVC:Y(XNTAC}- JF,9 31C.:A 15. GENERATOR'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 labeledlpfacarded,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 EPAAcknowledgment of Consent. I tort fy 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 16.International Shipments 1-- ❑Import to U.S. ❑Export from U.S. Part of entrylexit: a Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials LLI ]�— Transporter 1 PrintedlTyped Name, Signature; Month Day Year O a 4Z4 Transporter 2 PrintecTryped Name Signature Month Day Year 9 F-^ 18,Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residuej j ❑Partial Rejection Fuli Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ CS W Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 01. z. 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a DTSC With 30 days: PrintedlTyped Name Signature P.O Box 400 Sacramento, CA 95812-0400 EPA Form 8700.22(Rev.12-17) Previous editions are obsolete.