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-Ali ea'se print or type. (Form designed for use on elite (12 -pitch) typewnter.) Form Approved. OMBNo. 2050-0039 <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2 Page 1 of <br />3 Emergency Response Phone <br />4. Manifest TrackingiNumber <br />WASTE MANIFEST <br />ICAL00033Z79 <br />1 <br />1•$-78[P"7 . J <br />O O 6 l Cr 1, ij FLE <br />5 Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Tracy Lops dca DBA Stockton Lu lca LLC <br />4199 Ofteftim Q. <br />Staatdcxt, CA 9&M <br />Generators Phone: <br />J. Transporter 1 Company Name U.S. EPA ID Number <br />Ad%WNmd Carl icxt T"Wil rt Inc. (Sl!) 1"..AR00007F W <br />7. Transporter 2 Company Name US. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Ai CI TMd� �1J00�0l <br />rdV BMt <br />Altwxtuelqu NAA 87107 <br />Facility's Phone:49{2Q <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 />1 No KCd2k Hwavdill Wash Sold (Qty Sofil <br />P <br />362 <br />W <br />2 <br />2 <br />W <br />3 <br />4 <br />14 Special Handling Instructions and Additional Information <br />Plujililit Fknlbw Ill DOoIYFmot *: UTA7+ <br />.._. �--- <br />1)EFIll ACt8�16TRX=_4-,=�•,i 9 C- V. `:. (I � <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 geni is true. <br />Genera7fferrs PnntedirType 5Name Signaturear n ay e <br />_J <br />1— <br />16. International Shipments <br />❑ Import to U.S ❑ Export from U.S Port of entry/exit: <br />Z <br />Transporter signature for exports only) Date leave U.S.: <br />IX <br />W <br />17 Transporter Acknowledgment of Receipt of Materials <br />IX <br />Transporter 1 Printedlfyped Name Signature on ay ear <br />QTransporter <br />2 Pnntedlfyped Name ignature Month ay Year <br />18 Discrepancy <br />18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b Alternate Facility (or Generator) U.S. EPA ID Number = ^' <br />J <br />U <br />LL <br />SC <br />SEP P o 8 M;5 <br />Facile 's Phone: <br />W <br />1 Bc Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />e 1ti <br />z <br />(7 <br />.. <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />N <br />LLJ <br />1 <br />12. <br />3. <br />4 <br />esignated Facility Owner or Operato Certification of re f hazardous materials covered by the manifest except as noted jn Item 18a <br />edlTyped Name 2 / Signature i Month Day Year <br />F'P <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />