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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3 Emergency Response Phone 0. ManifestT aclu g Number WASTE MANIFEST 1 C) re i ,III 1 1 JJ K .5. Generators Name and Mailing Address Genemtors Site Address (if different than mailing address) Ir Generators Phone: - - 6. Transporter 1 Company Name r r,_ U.S. EPA ID Number 7. Transporter 2 Company NameU.S. EPA ID Number n - t c BF_ . ass'Fz I , _ , %t 8. Designated Facility Name and Site Address „ r i::'s a as. `I y ,f U.S. EPA ID Number > 1_ ..: Facilirys Phone: 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 Paddng Group (d any)) No, Type Quantity Wtivol. 1 1 OQ K Z 2 W 3. 4. 14. Special Handling Instructions andAdd honal Information ILI . . . _ Illy 15. GENERATOWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if i am a large quanfily generator) or (b) (ifi am a small quantity generator) is his. Generatorsl0fferors PrintedRyped Name Signature Month Day Year 16. International Shipments f— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit ? Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAdawwledgment of Receipt of Materials Transporter l PnntedRyped Name Signature �..� - Month Day Year a � I _. QR Transporter2 Printedrryped Name �r Signature '— Month Dayl Year K r 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type Residue ❑ Partial Rejection Full Rejection ction Manifest Reference Number. F 18b. Alternate Facility (or Generator) U.S. EPA ID Number zi U <a Facility's Phone: w 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q z Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) Jotice: State of California requires 2. 3. [enerator to photocopy and mail to 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest ded in Item 18a 3TSC with 30 days: - Pm tedlryped Name i.0 Sox 400 iacramento, CA 95812-0400 /Mp, /k ' EPA Form 8700-22 ev. 12-17) Pre is editions are obsolete. GENERATOR'S INITIAL COPY