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**Generator, Mail a ropy to: D"+ SC P.O. Box 400 Sacrannento, Ca. 9.58,12 -MO within 30 days. <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />N!m <br />2013 <br />IEN <br />RTMS <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. �` DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1 eraftor^ID Number �1 <br />� %i� <br />2. Page 1 of <br />3. Emergency Response Phone <br />Numbers <br />4. Manifest TrackingF <br />. , <br />4 <br />WASTE MANIFEST <br />ti FJ�'✓C� T.v7 — <br />f <br />800-424-9300 <br />,3 in, <br />5. Generators Name and Mailin AAaa��ess ` Generator's Site Address (if different than mailing address) <br />.��a_ G vt, ;Gs <br />.. <br />�r —J 9.:;N 0 04 <br />nerators' Phone: " <br />GeV <br />" �' <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />': ENVIRON <br />, �, Envlrortm rttat �4t ries cAD98r° <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />E,v.�rgre©n 011, Inc, <br />6880 Smith Ave. CAM80887418 <br />Newark, Ca- 94M <br />Facility's Phone: 510-796-4400 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1idrrr�a�3lP/il�d'>� <br />z.ib'iJA6t9�#5`�irG��l�o•S, <br />3.�1 <br />eve <br />3.1V <br />E <br />4. <br />14,6 ecial Han ing Ins ti s aAdditional Information <br />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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport 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 Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator rocs Prin /•type Name Signature Month Day Year <br />_J <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />CL <br />Transporter 1 Printed/Typed Name Signature�� � Month Day Year <br />QTransporter <br />2 Printed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouanti ❑ <br />ty El El Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />U <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1 <br />2. <br />7 /—//v / <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Iten)18a <br />Printed/Typed Nam Signature Month Day Y =.riOi 1311,, <br />N!m <br />2013 <br />IEN <br />RTMS <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. �` DESIGNATED FACILITY TO GENERATOR <br />