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Pleose pririi or type,(Form designed far:use on Ilse 1.2 pitcpewrifer. - Form Approved.OMB No.2050-0039 <br /> UNIFORM HA7AR60US 1;�3erx�Ator ID umber 2.Page n nF s n king Number <br /> WASTE MANIFEST C3gg 'T j 1 9,17030 J J K <br /> 5.Generators Nafno and Mailing Addre _ Gen eitors Site Address(if different than malllrg'atldress) <br /> ..,.; iVr4•TlOhd.a,L.P�t?I�f.Jiai S-�oC���,. ' _. . <br /> 713 N EL 00RADri ST- J U L .10 2014 <br /> STOCKTON,CA <br /> Ge eraiors Phor§ Z ZaIgzg <br /> Transporter',(,ornpany NBma EN ber <br /> FtWOS' e;n R>`,f MENTAL ERMC'=; iPlr:.. ENVIRONMENTAL <br /> DEPARTMENT <br /> 7.T 6 2 Compa y Name U.S. PAD Number <br /> 8•Dasignstad Facll)iyName and Sipe Address U.S.EPA IU Number <br /> 315iJaST F'lCC181� t. <br /> CAL Ct1tY&2)4i.+`5 <br /> �A3•ux1�e.ES,CA �7�;3 <br /> Fast 's Phone:WD-4394145 <br /> 9B, 9b.U.S,DOT Description(including Props Sttipping Name,Hazard Class,ID Number, 10.Cantalners 11.Total 1g:Unit and PaCking(}oup(if any)) i.Wasie Codes <br /> 40. Type Quamiy wt.lVol. <br /> tY 1. IStrI1M.3.WA M.GASI )1_NI —,S,POIf 001 stat 1G "ad X11 I i <br /> ME 2 <br /> LL14. <br /> I I <br /> 3. <br /> r <br /> 14.,OerialHanding instructlonsndAdditl(jnal;m3onti , } ,«C:3PfTFAGT+.)R.' RAiAOSRat.1117 rI'I,4.(ULFIRr,,.i• ;�HWI-D 8E IEAI .no 1.�Se.APPROVED I <br /> 15. GENERATOR'StOFPEROR'S CERTIFICATI : I hereby declare that the conteMs of this consignment are fully and accurately described above by the proper shlpp!m name,and are classified,packaged, <br /> rilarred and!ebeledlplacarded,and are In all aspects in proper condition for transport ar�ording to Bpalicable internat:0nal and national governmental regulation?,If export shipment and I am the Primary <br /> Exporter,I C$r*that the contents of this Cons! nment Conform to the terms of the attar..hed EPAAcknmyledgment of Corsent. <br /> I certify that the waste minirr:zatirn atatEmant i entilled in d0 CFR 262.27(x)(El am a large quarrtfey generator)Dr(b)(if I am a srnall quantity geni rat0r;is frue. <br /> Generator's/O feror'g p)1ntedlfyped Name Signature Wenth Day Year <br /> - <br /> 16.In ematlonal5hipments 1:1Im rtto .5. rr '' <br /> Fa u Export from U.S. Port of entry/exit: a <br /> Transporter signature(for exports ori <br /> g P N)' Gate leafing U.S.: <br /> w 17,TranspaierAcknowledgmentafRecelpt of,Mate' <br /> re Transporter 1 Pdnted`TV ame Signature J _ Mi,nin Day Year <br /> O i- Ate) f <br /> /;�� <br /> F."y- <br /> 2E Trawo r o Name Signet Mon r <br /> CC . P <br /> t" J <br /> 1 H.DIScrepancy <br /> 18a.Ulscrepancy indicaPwn Space poop' ❑Type <br /> Residue ❑Partial Rejection ❑Full Roieulloh <br /> Manliest Reference Number <br /> IOb,Alternate Facility(or Generator) U.S.EPA ID Nipmber <br /> v <br /> Facility's Phone: <br /> 18D.Signature of Alternate Fac 1 t,'tort Generetor) . Month Day Year <br /> 19.Hawardous Waste RepDrt Management Method es(1•e•,codes for hazardous waste treatment,disl:ma;,and recycling systems) <br /> 2D.Designated Faali y a,mer or Oparat0r CFrUflrary Gf reC6ipt Dr hazardous materials covered by the mah fest exempt a fie <br /> le rrypetl Narne Signature Month ay `(h <br /> Ana Ja <br /> � <br /> EPA Fonn 8700-22(Rev.3-05) Previous editions ara obsolete, DESIGNATED FACILITY TO GENERATOR <br />