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co <br /> 'Please pPint or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generaier ID RUmbei 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST G B F <br /> 5.Gereralor's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> INTERSTATE TRUCK C.ENTEIR 132.5 NAVY OR <br /> P O.BUX'6163 STCKKION,CA 96204 <br /> STOCkTON,CA 05'2 1 <br /> Generators Phone;MM otgA.Aemi <br /> 6.Transporter 1 Company Name U.S.EPA ID Number i <br /> uF#�',�P WAIRDS So l.:E. IONSi,ifi#C 1i�T <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 0 Number <br /> C+EM-RAIdC;FII�Ct:IF?�WA,LL(.. U.S. <br /> 1111155LVF�TE ROCK R€�. <br /> R NCIta C C�RGC�VA,CA 05142 <br /> Facility's Phone: 13116. 5f•n1�Bt3 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,iD Number, 10.Containers 11.Total 12.Unlit '13.Waste Codes <br /> HM and Packing Group(iFany)} No. Type quantity Wt./Vol. <br /> 1. <br /> W04 r lfleiie hnoti"rcee�gILcOPKIly),21, 1 {N' 10P U0�1 3�1 <br /> W <br /> Z 2. i <br /> LU <br /> i <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> PR(YRLE#87521,MSC:EENT AERC6011-6,ER-4#128 <br /> AWW"ATE,MOTRINE CLOT"40 <br /> 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 laboledlpiacarded,and are in all respects in proper condition for transport according to applicable International and national governmental ri$,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. i <br /> 1 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 enerator)1s true. <br /> Generator's/ roes Pd yped Na Signature Month Day Year <br /> 16.Int a hlpmen s ❑Import to U.S. ❑Export from U.S. Port of entry/exit: _ <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transport&Pintecirrypied Name / Signature Month Day Year <br /> a e S /d <br /> Q Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> � I <br /> ~ i <br /> 18.Discrepancy 9 <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑TypeI <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ZJ- <br /> U , <br /> LL Facility's Phone: <br /> 18c.Signature of Aitemate Facility(or Generator) 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) I <br /> UJI <br /> 0 1 2 3. 4. <br /> t <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinledlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />