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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M if rst Tracking Number <br /> II} WASTE MANIFEST CAP,0 0 0 2 1 6 5 5 6 _ (ty01424.9.',00 14 0 5 7 7 2 8 JJ K <br /> I 5.GaneretpfsN"RINd.Irlsilj ITLOACS0 Generator's Site Address(if different than mailing address) <br /> 2222 S SINCU+IR40VE - <br /> STOCKTON & 95215 <br /> Generators Phone: 9 774-5000 <br /> 6.Transporte�tCo a a U.S.EPA ID Number <br /> ASHl1IY�,�1`I DNMENTAL.SERVICES C.A D 0 2 82 7 7 0 3 6 <br /> 7.Transpoder 2 Company Name U.S.EPA ID Number <br /> 8.Design�t�d,F,ppJiN.Name OLOGIE9 LLC U.S.EPA ID Number <br /> 5375 SOUTH AVENUE <br /> LOS ANGELES CA 90058 C A 0 0 9 7 0 3 O 9 9 3 <br /> Fadill 's Phone: 3)277-.1500 - <br /> ga, go.U.S.DO- n(Including Proper Shipping Name,Harard Class,ID Number, 10.Correll am 11.Total 12.Unk 13.Waste Codes <br /> HM and Packi (if any)) _ No. Type Quantity WWol. <br /> 17-71 I m RZAREPOUS WAS I F SUM tot..totl.l FULILTST— <br /> D <br /> W 2 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information / <br /> EMERGENCY CONTACT:CHEMTREC 1-800.424,9300 NAERGN 961:171 f PROFILE M 981 AP203554 OILYSOLIDS <br /> P500-00015770 w APPROPRIATE PERSONAL PRdTECTIVE EQUIPMENT <br /> i J <br /> 15. GENERATOR'SIOFFEROWS 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 cedny that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)is true. <br /> Generalorci0fip%fs dntegityped Name y / / / SignpNre Month Day Year <br /> --t <br /> 16.Intematonal'6rumnems 7 ' <br /> F Import to U.S. E]Export from U.S '��" Portofentry/4' <br /> Transpoder gnature(for exports only): Date leaving U.S.: <br /> w 17.TransponerAcknowledgment of Rampt of Materials <br /> Transporters Pdnted( cl Nam, Signature ~J/ �/ Month Day Year <br /> a Transporter Printedtfyped Name 'Sgnature Month Day Year <br /> K <br /> 18.Discrepancy <br /> 18a Discrepancy.Indication Spars ❑ Quantity E]Type <br /> ( � / [I Residue/. El Partial Rejection ❑Full Rejection <br /> LCc�fic♦♦II// <br /> t1_r l i't./( !"1 i•d'li• �G"x190 C Y{C(:.f rt,/U /4i / /� Manifest ReferentevfJumber: <br /> 18b.Altern*Fa k (or Generator) U.S wr <br /> U <br /> IIVD <br /> tX Facility's Phone: <br /> H18c.Signature of Alternate Facility(or Generator) r a .`. Day Year <br /> tR <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) L' NLar11TAL Ft1✓esY}9 <br /> r` / 2. 3. 4. r NTlSE.si'^;,E3 <br /> r f <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ! <br /> i <br /> Printe yped Name Signature Monts <br /> x / �^� —..-.v. pay Year <br /> r . r".. //;'� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />