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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 a.Manifest Tracking Number J J K WASTE MANIFEST 5 Generator's Name and Mailirg Address Generator's Site Address(if different than mailing address; Generator's Phone 6 Transporter 1 Company Name U S EPA ID Number :MNle A44 'Al ( r WAs 1I t 01 .14 7.Transporter 2 Company Name U.S.EPA ID Number *(*?t L�Wliit 1�t(rtk/� ,1-b1 tMS Mh 8 Designated Facility Name and Site Address U.S EPA ID Number r UM/A It I:b'l WAb 1 L I NAHS+I W F Ai N}1 Y fINA)I IS hM~tr 1i6 s 1 MrW AZ li Facility's Phone.'J.1i.13 ii?f t ga 9b.U.S DOT Descripton(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 d' O Q W z w 4 14 Special Handling Instructions and Additional Information 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 labeledi placarded.and are in all respects in proper condition for transport according to applicable mtemationaland 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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's10fferor's PnntedfTyped Name Signature Month Day Year 16 International Shipments ❑Import to U.S ❑Export from U S Port of entry/exit ? Date leaving U.S Transporter signature(for exports only). rY 17 Transporter Acknowledgment of Receipt of Materials LWJ Transporter 1 Printed/Typed Name Signature Month Day Year IXO CL Z Transporter 2 Printed Typed NameSignature Month Day Year 18 Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Rejection Manifest Reference Number >" 18b Alternate Facility(or Generator) US EPA ID Number H J U lai Facility's Phone. MonthDay Year Lo 18c.Signature of Alternate Facility(or Generator) a Z 19 Hazardous WasteReporManagementMethodCodes(ie codes for hazardous waste treatment,disposal,and recycling systems,lin Notice: State of California requires 0 1 2 3 generator to photocopy and mail to 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18 DTSC with 30 days. PrintedRyped Name Signature P.0 Box 400 Sacramento, CA 95812-0400 EPA Form 8700-22(Rev 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY