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Please print Cr type. (Form designed for use on elite (12-Ntoh) twewfilecl <br />Fmm� Annmvad f1MR Nn )nr;Rnn90 <br />EPA I= 6700-22 (Rev. 3.05) Previous edition em obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />i:l <br />ENTAL <br />rqA lr <br />UNIFORM HAZARDOUS 1. GenarCADlDNixiter 2 Pegs 11of <br />3. Emergencyi o Phone <br />---- --- <br />4 f�t a <br />WASTE MANIFEST S <br />253 <br />�Imrba <br />014895144 JJK <br />5. Nomaenrdd MM�epa�gAddre Gin She Addran /Iifdliferantqq��nn meirsg edemas) <br />mvelsilyOt7tiePari c raityOtThe PaeMC <br />3601 Parc Ave 3601 Pacific A e <br />Stockh3n,CA95211 Stockton, CA95211 r E■■�^' <br />. , - <br />Geromex'sPhons: 2D9-94&-2908VVV - <br />6. Transport 1 Company Name U.S. EPA 10 Number <br />Ingenlwn (MlphesxERl PHONE -coral IDN a76fi 0002) CA12000179747 OCT u U <br />7. Transporter 2 Company Name US. EPA 10 Number <br />Clean Harbors Envlronmenlial Serdoaa U40039322250CN VARNm <br />80 naledF Sty Narrow d5' Addmss U.S. EPA ID Number -`CA,VUnt:0a <br />Ctean �er6ers �a ,LP. <br />500 Battleground Road T)0982290140 <br />La Porl TY77S7i <br />Fadli, esphone: 291-476-0646 <br />9, <br />9b.US. DOT Daxaipeon(mcknig Proper shipping Names, Hazard Clus, ID Number, <br />10. Conletrre <br />11.Tatel <br />12. Une <br />13. Metals, Co11 da <br />Ne. <br />Two <br />HM <br />and Penift Group of any)) <br />gaassol <br />IVIw <br />1 UNi 013, Carbon i inidde, 2.2 , <br />141 <br />�cy <br />el <br />W <br />W <br />2UN10115.Rmmonie, anhydrous, 2.2 ,Poison Inhalation Hezald <br />141 <br />i� <br />X <br />3. <br />4. <br />14. Gpedal Handling Irshudlens and Additional keorma <br />ment D8452 Sales Order 9,181 <br />1)ERSk64R2 DOTERG020 UPL-5021LCY4JCY11v1VWN4440 /A) <br />2)ERS#6482 DOT ERC Ill UPL-501 1 LCY5 7 CYLG i e ibli sa ^- • aV1ian. Mie, <br />15, GENERATORWOFFEROR'S CERpFICATION: Ihereby declare that he mnbrds of thecomignment am lily and scwmely dosarosd above by the poper shipping name, and en classified. packaged, <br />narked and ebeedfplicadsd, and am In all mal In proper coo ton tr transport eaardng to appllcatye International and nadand gowsmnenal reguleEare. If mmee shiprnenl said I am the Prmery <br />Exporter, I cerby that Ne comenua1dre oem oat ounform to the "a of Use ettaMW EPAAUaeNtedgnenl of Consent <br />I cadtTy that the wade minkrimlim statement Idealfmd In 40 CFR 262.27(a) (I I am a large quantity generetaq or (b) (Ifl am a smelt quantity generator) Is we. <br />Genararyrarceemrs PdnladRyped Nene SlgnaWe ne Day Year <br />INVAin 4, I <br />—1 <br />F <br />16. nterShipments <br />❑Import to U.S. Expos from U. S. PoAWe&*oi:__ <br />TranspMer ngneture (for exports ony)', Dme leaving U.S.: <br />w <br />17.TmneponuAc4vmedgmmlof RecaoofMeerkas <br />Tmmp>tter 1 Pddedlfyped Name Slgnatum Mora Day Year <br />J <br />a <br />Trampaler PrInenptyped Nemo Signstw Month Day Yee <br />19. onutowey <br />16a Dlsampency Indication Spur ❑ Gusmay, ❑ Type ❑ Nemdue ❑ Partial Reiecbbn ❑ Fus imiKllon <br />Ma,asel Refamna Number. <br />tai Mmrnata Fool (or Gatemer) US EPA ID Number <br />V <br />u <br />Fedgy's Phone: <br />W <br />1ec Signeaneol Alternate FXRY (of 0;;M N <br />Month Day year <br />a <br />z <br />h19. <br />Hamrdous Waste Report Management Method Codea(i.e., codes for hexsdoue wants treatment deposal, and mcyding system) <br />1. <br />2. <br />3. <br />4. <br />-20. Daelprsed Fadllly Daear a Operator: Cerbrwtisn of model of heaamous mal mvamd by all manfest exupl as rated in Item 19a <br />PrintatirTyped Nam Senators Month Day Year <br />EPA I= 6700-22 (Rev. 3.05) Previous edition em obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />i:l <br />ENTAL <br />rqA lr <br />