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Please print or type. (Form designed for use on elite (12 -pitch) typewrit4r.) J 'V Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS 1 GeXqra ID u er ' C R 5 0 8 2 5 1 2. Pa� e 1 of 1 cuBesoonse Phone r' 4, Manifest Tracking Number X0769010 JJK WASTE MANIFEST 0 5.-CJK1fksHailing Address (.(��s (if different than mailing address) Acta: Rat GU§err Baty, 5200 Shone Street 1990 PiCCC91 Rd. C Twirterce CA 9040 Stockton CA 95216 3 2 3 6 2 0 J Generators Phone: 6.T&yMICi nS4areC, AI U S 0 0 i 2 g 0 �EPA 7.TrranspoQer 2 Company Name U.S. ID Number B.LBgpJaefnd Site Address U.S. EPA ID Number 1630 W. 17th Street Long Beach CA 90813 6624 432-54445 C A D 0 2 8 4 0 9 0 1 9 Facility's Phone: 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. o X13. ;.7q ISM, 9VAS !-E AVOSM3 2.1(aell"O ds)DM X01 1331 3413 Z LLiFLi 2. 3. to ,.NryRLU MJ i I 4. JUL 2 8 i 14. Special Handling Instructions and Additional Information 9b.1} Aerosols Profile#5119?_ ERG 126 F _ _.....-� gEpARTfdEt .. Gloves & Goggles i� U"ISI-1 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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generatoe.sl7eirols Prince ed Name Signature Month Day Year /. -J H 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: It 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typ Name Signature Month Dayy Year / ' N Transporter 2 Printed/Typed Name Signature Month Day Year a rr 0 H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection TIM RE E'RENCED WAS'I8 WAS RBCL+Nm, F1AND nifest Reference Number: >- I- 18b.Alternate Facili r OVERTON, INC. OPERATES THE FACIt RY roll 'U.S. EPA ID Number ` ty bPft.G�'9 NTED TO Tt(EN, BY TFff DEPARTS¢NT OF TOXIC SU%STANCE CO NTROL MGrllV rllr T}tE ENVIRONMENTAL PROTFCIION AGENt'Y PI ACCORDANCE WIIft TIM PRUVISIt1NS FtE RESOURCE LL OF CONSERVATION AND RECOvTxy ACT OF 1976 TOGETfIFR w PFR Facility's Phone: NERAL AND STATE REGULAQF0bts WITH A.ICAB NECESSARY Month Day Year 18c.Signature ofAltACCORDiY ENCED WASTE AND AL1. TM WASTE HAS BEEN HAMD1.8D Z z 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest excepts noted in Item 18a Pri ted/Typed Name Signature \ Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR