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Please print or type.(Form designed for use on elite(12-pita, pewriter.) Form Approved.OMB No.2050-0039
<br /> F1UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS WASTE MANIFEST CAD?B1573979 _ i 0 �.7 K�7
<br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address)
<br /> :�'i�1TIF;�T0'fI~, T�i't.iCK G�tITE�t
<br /> A FTH I,3 R FARREL L Ertl Pik 6463IY8 5 MAY
<br /> s iaCl�'t'{`spy CA 95206 0463
<br /> Generators Phone: 209-944-5821
<br /> 6.Transporter 1 Company Flame U.S.EPA ID Number
<br /> SAFE", ,,KI,FEt4 .STS,Ft13, IN'iC.
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> B.Designated Facility Name and Site Address ,rr"tfi� , { , r U.S.EPA ID Number
<br /> ET1^F,�.c�l� SYSTEM, INC. Qi�r�4+7c��
<br /> 600'(1 89TH STREET
<br /> Facility's Phone: _
<br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Narne,Hazard Class,ID Number, 10.ContainJType
<br /> 11.Total 12.Unit
<br /> HM and Packing Group(if any)) No. Quantity wtivoh 13.Waste Codes
<br /> W3t',.PVFR HAZARDOUS 1JASTE i_:I:�tUID C 334
<br /> 4wr,>j_'t.f,US PA TS WASPEtw
<br /> U-1
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<br /> 4.
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<br /> 14.Special Har:iillng Instructions and A u!Oonal lnformaii.rn s1I? t $S 1 C 8 43 e a L 1 24
<br /> X5370287' 0742
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked a,,d iabeiedlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,i cerlify that the contents of this consianmert oorforrn to the terms of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> Generator'slOfferor` Pnntou!T7ped Name
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<br /> Si riajure
<br /> Year
<br /> .J- !' � �; .!, '� ,,� f�' P �„` ? ...«: ._,.:. _.. e'er..f _..� ,�...b��Grr' ,•a,.�,..a'�',"�,�,.. `4''r �,,,�i r' D��, f
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<br /> � 16, nteVion I Shipmehts
<br /> r ! yr
<br /> Import to U.S. ❑Export from U.S. Port of entry/exit:
<br /> Transporter signature(fol exports only): Date leaving U.S.:
<br /> UW 17.Transporter Acknowledgment of Receipt of Materials
<br /> X Transporter41 PHntedrryped Name Signature -
<br /> O
<br /> Month day Year
<br /> Q Transporter2 Prince!Typed Name Signature�- Month Day Year
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<br /> H
<br /> 18.Discrepancy
<br /> 1 Ba.Discrepancy Indicalici,Snare Quantity ❑
<br /> Type, ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference H Number,18b.Alternate Facility(or Generator) U.S.EPA ID Nurrber
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<br /> LL Facility's Phone:
<br /> LCI 1$c.SEgnature of Allernefe Facility{or G^cara,or) Month Day Year
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<br /> U) 18,Hazardous'PJaste;deport Management Method Codes(i.e.,cod"for hazardous waste treatment,disposal,and recycling systems)
<br /> men3• 4.
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in tem 18a
<br /> Printed[Typed Name Signature Month Day Year
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - GENERATOR'S INITIAL CORY
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