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Please print or type. Form Approved-QMB No-2050-0039 UNIFORM HAZARDOUS 1 Generator IQ Number a Page 1 3 Emergency f3eseonse Phare 4.AEanifestTradking Number WASTE MANIFEST 11- JJ f1 5.Generator's Name and Mailing Address Generator s SiN,-Addfess jif different than Trailing address) Generator's Pharr 6.Transporter 1 Company Name U.S EPA ID Number (- ;I JJW 7 Transporter 2 Company Name U-S-EPA ID Number C ARM 175427 S.Designated Fadlity Name and Site Address U.S EPA ID Number ir.•;.. .-� •run i+-.-,- . . .. - Facility's Phone: 9a 9b.U.S.DOT Descriphan(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11 Total 12 UnA 13 Waste Codes HM and Packing Group litany)) No. Type Quantity JVt Nol 1 r, ^ Q tst LLI 0 i + f '.t Special Handiing Irsvuctions and Additional Information 15 GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cons+gnment are fully and areurately described above by the proper shipping name•and are classed.pad*aged, marked and iaheledlplacafded,and are in all respects in properGnnd bon for transport according to app cable internatrcmaland national gmremmenial reguda6ons.If export SNpment and I am the Primary Exporter.I os tir%that the corrtents of this ccnsignrnw confsrm to are terms of ft attached EPA AchraQwtedgmeht of'Consent. Certify that the waste minimization statement identified in 40 CFR 262.27(a)(it i am a large quantity generator)or lb S Iif I am a small quantity generator)is true. Generator sl4fferoePnnted•rTyped Name Signature Month Day Year 15 Intematbnad Shipments F ❑Impart to U-5. ❑Export from U 5. Por at entry!®zit: Transporter signature(for exports only) Date leaving U.S.- W 17 Transporter Acknowledgment of ReoWl of Ma*ais Transporter 1 PnntediTyped Name Signature Month Day Year Q a Transpcvter 2 Printed-Typed Name Signature Manta Day Year %Discrepancy 18a.Discrepancy Indication Space ❑ Qanb ty Type Residue Partial Rejeclmn �Full'Rejection Manifest Reference Number F 186.Altarnate Facility for Generator) U-S.EPA ID Number J_ C3 Lei Facility's Phone- w I&Signature of Aftemate Facility(or GesreraWr) Month Day Year f- Q 2 15 Hazardous Waste Report Management Method Codes{ie,codes for hazardous waste treatment.disposal,and wyding systems) Notice-State of California requires generator to photocopy and mail to 20 Desgnated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18 DT5C with 30 days: Printed:'Typed Name Signature P.❑Box 400 Sacramento,CA 95812-0400 EPA Forrn 87DQ-22(Rev 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY