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-Gs((erstni-,nsi e y to:1TiSC,P.O.B=400,Setermwto,CA 95400 W ffih 30 days <br /> Please print or type.(Form designed for use on elite(12-p rh)typewriter.) Farm Approved.OMB No.2050-0039 <br /> I'IIFORM HAZARDOUS 1.Generator ID Number 2.Page 101 3.Fmegenuy Response Phone 4.Man"rfest7acking Number <br /> -WASTE MANIFEST cAL000.976808 1 1-800.424- 00 011570275 JJ K <br /> 5.Generators Name and Mailing Address Generators SPACWIV <br /> it-Addddress(ddftenent than mal9ng address) <br /> 4_W Q LLC A� PERFOFaA4NCE C62 <br /> 4545 QANTAS LN . 1110 <br /> STQCKTIK GA 95206 STOCKM CA 85208 <br /> Generators Phone: . 209-983-1940 r <br /> ." 6.Transporhrl Company Name,' U.S.FPAIDNumber <br /> SAFM-KLEEN SYSTEM NC, 7XRODOd8i205 <br /> 7.Transporter 2 Gompay Name U.S.EPA ID Number , <br /> 6.Designated Fa 60 <br /> y Nameand Site Address U.S.EPA ID Number <br /> EVERGREEN QL <br /> SM) AVEM1c CA0980887418 <br /> NEWARK, CA,94560 <br /> Faalirys Phone: 51 t3-795-4100 <br /> Is, 91b.U.S.DOTDescription('mdudmg Paper Shipping Name,Hazard Claw,ID Number, 10.Contalners 11.Tocol 12 Unb <br /> HM 'and Packiig Gmup(darth) 13.Wada Codes <br /> No. Type �6ty WtAkl. . ,e '. «' . . <br /> o N06i-RCRAKVAF=SWASTI:LiOW(OLYWATER) ..� <br /> TT <br /> Z. 2. <br /> w r <br /> 3. i <br /> 1 <br /> j <br /> 4. <br /> 1.. <br /> i <br /> 14.Spedal Handlig Instructions and Additional lnbrmabon <br /> A. 79407 MG 171-9b1 <br /> N ( 160924 t#: <br /> f. <br /> 15. GENERATOR-S)OFFEROR'SS,,CERTIFICAnION:I hereby dedam W the contents of Ws consignment are fully and accurately described above by the proper sh'ryping name,and areclassified pad®gaq <br /> marked and Fabdetl/plararded,coq are In�faO aspects in proper cond'b�n for transport according to applicable International and national governmental regulations.If expod shipment and I am Ne Pdmary <br /> Fxporter,l certy Dat the cantena of this consignment cenlarm to the I. of IN attached EPAAdmowledgmenlof ConswiL <br /> I certify that the wasa minimization satemanl Identified In 4D CFR 2"(a)(I I am a large quantity generator)or(b)(d)ama area0 quantly ge nalw)Is bue. <br /> C�eatces/OBemr 'nte[lr"Name 4 Signature Month Day Year <br /> Se �Lau-0 r,1 ,. �72 ;rrr.'-• <br /> 16.Interretiogal Shipments <br /> r ❑Importio U.S. ' ❑Egsorl from U.S. Pmt of enby/edt <br /> 'Z Transporter signature(kf exports only): Date leaving U.S.: <br /> w 17.TrarspoderAdmowiedgnenlufRae* fMateriaa <br /> Tansped r 1 pyintedfryped Nam Straw Month Da. Yaw <br /> CL <br /> �� <br /> za Tansportw 2 PraecVTyped Name SIgrgWre Mph Day Year <br /> 18,Disueponq--� <br /> 18a.Discrepancy Indication Space ❑ Quantiy ❑T <br /> type ❑Residue L1 'a FiAReJection <br /> Manifest Referenee Number. ki L i - -"" <br /> 18b.Altemate Fatir4y(or Ge m-ter) U.S.FPAID Number <br /> AUG 6 2015 <br /> LL <br /> Facility's Phone: ' <br /> 18c.$JlaloAeFacility Generator) <br /> FG yCJjI TrJ r1CDg, AAC -Year <br /> sC <br /> 5 19.Hazardous Wastt/eReport Management Method Codes(m,codes for hazardous waste beabnent dusposal,and recycling systems) <br /> C 1. ( FI 2. 3. 4. <br /> 20.Designated Facft Owner <br /> or Operator.Certiacation d mcelpt d hazardous materials covered by lhownifeil except as ed in be 14 Mop <br /> PdntedRYDGJs'S\atu�� l� T y (' l <br /> FA Form 8700-22(Rev.3-05f Presioos editions;are obsolete. DESIGNATED.FACILITY TO GENERATOR <br />