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Please piint or type, Form Approved.OMB No.2050-0039 <br /> ? URFORM HAIARDt]US 1.Generator ID Number 2.Page 1 of 3.Emergency Reapanse Phone 4.Manifest Tracking Number <br /> WASTE fNANIFI?ST A L 0 €k 0 3 9 0 0 5 3 j ��-��# ��� 0 ,22071063 JJ K <br /> 5. ! is i � M trf3 address ene ator's S 1e Adryss ! t than mW IN addreas) <br /> ��st 2650 N Macaftllrty Qr <br /> limine CA 92614 Tracy :A 97376 <br /> Genprarpr's Pbana: 5 4 9 a 9 $ - S a 2 6 <br /> B. spprler t Company Name U.S.FPA ID Number <br /> iw�!°11 �3F:i�I�I1�3r I f t �C x. kW-, C .A 8 0 0 0 2 1 7 5 1 3 <br /> 7.Traorsporter 2 Company Name U-5-EPA 10 Number <br /> 8.P9� �[�1Cartd Site Address U.S.EPA ID Number <br /> 1IN W.Mop—to Avenue <br /> f340orninglon CA 9127316 <br /> Facility'sPhone:909 421-2012 IC A D 9 8 2 4 4 4 4 8 1 <br /> ga. 96.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers It.Total 12.Unit 13,Waste Codes <br /> HM and Paddng Group(If any)] <br /> N0. Type Quantity Nft,Not. <br /> ,xs nr .rtI,t1___�., <br /> C) <br /> Z 2. G A� >Z _0_14 gj4l tf�jp A1� lJv <br /> �°Idso l+r�vi pc �S c/W i]�P�S�j // 0 <br /> ,U <br /> a <br /> s <br /> 14.Special Handling instructions and Addillonal Vonalicn r)[•-,` r. wu. r <br /> 15. GENERATOR`SIOFFEROR'S CERTIFICATION: I hereby declare that the cantalts of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and•labefedlplacarded,and are In all respects in proper condition for traneporl according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Admowledgment of Consent. <br /> I cerfify that the waste minimization statement Identified in 40 CFR 252.27(a)t5I am a targe quantity generalm}or(b)(if I am s small quantity generator)is true. <br /> Generale fferor's Prw yped Name Sign' e Dov 7year <br />� 36.lntemafional Shipments <br /> Impart to U.S. ❑Export f U. Port of entrylexit <br />? Transporter signature(for exports only): Date leaving US.: <br /> 17,Transporter Ack€mwbdgmentofReceipt ofMaterials <br /> Transpo or P i t d ped Nan l Segnanxe Month Day„ Y ar <br /> 2 Transporter 2 Print 0yped Name Signature hionO Day Year <br /> F <br /> M.Discrepancy <br /> 18a.Discrepancy Indication Spars 1:1 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b-Altemete Facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> U <br /> FacYlty's Phone: <br /> W 18a.Signature ofAftemate Facility[or Generator} Monln Gay Year <br /> J.- <br /> 19. <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> f. 2. 3, 4. <br /> 20.Designated Facility Owner or Operator Certiffeatlon of receipt of hazardous materials covered by the manifest except as noted In Item 1Ba <br /> Printed/Typed Name Signature w-onih Cay Year <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />