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-r °� RECEIVED APR307014 <br /> Please print or type.[Fon dxsi�ned Lo <br /> use on 8Iite(12-0tch}typawdten) FormApprdved. MB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Prone 4.ManHesf TmeMrg Number <br /> WASTE MANIFEST CALM122 2 8Q6-4'x$S N 011$0;669 JJ K <br /> 5.Generators Name and Mal'iig Atldreaa 1 Generators 58eAddress 0f dilferenf titan mailing address) <br /> SI irm f.l'tC'nitL¢C'RrX'C;lit% $Tetra�.PifA7liW1 <br /> '2302 TealCitrlr I(NO IrF4xc rot:G <br /> Gena aloes Phone: , .5 NV,19431 775-358 0888 stica4.nn,C.4,952(x6 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> World Fmvomnu»4aal&Enere}c e O Box 255,N, e5?SakhrMl 7r1O CA 95691 CAR000037?FYt <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Sea Address _. . ___ .._ .. _..___ .__.,._.__ _ - U.S.EPA ID Number - - - <br /> Reeologp Hay Wvd <br /> 6426 Hay Road <br /> 707-451 3276 Vacaville,CA 95691 <br /> Fecill 's Phone: CAf?982042475 <br /> ga, 9b.U.S.DOT Deacriptbn(IrMing Proper Shipping Name,Hamed Class,ID Number, 10.Containers 11.Total 12.11ntl <br /> HM aril Psch'ng Greupidany)) No. Type Dawlgy WINoI, 13.Wazh Codes <br /> L <br /> R.Q.,NA2212,ASBESTOS-9,FGMCiA <br /> \}, 1----�-- <br /> 3. <br /> 4 <br /> 14.Spedal Handling lnsmwtions and Additional <br /> Information <br /> EPA Region IX BAAQMD,939 Ellis Sheet <br /> San Francisco,CA 44109,(415)771-6610.Abasros;Removal RegWfemerif <br /> 40CFRti1,(Bagel,sealed,labeled). <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:Ihereby declare that the contents of this consignment are fully and acarafely descrlbed above by the proper shipping name,and are ciessified,packaged, <br /> madrad and lebeledlplacarded,and are M ell respects in proper condition for tmnspod eccaang to applicable International and national governmental regulations.If exportshipment and I am the Primary <br /> Exporter,I tartly that the contents of this consignment conform to the terms of the abashed EPAAcinowledgmaM of Censenl. <br /> cert ly that the wash mlmmlza6m statement identifled In 40 CFR 262.27(x)(if]am a large quantly gerserator)or(b)(el am a small quantity gencretm)Is true. <br /> Geiamtors/0111imors Pnntedrfyp e p Sig Men Da Yqar <br /> J 16 1filemainme campments <br /> - <br /> El wK to US. ❑Exg�lrom U.S. Pedofear'Y'. . <br /> Transporter signature(for exports ony): Dale leaving U.S.: <br /> w 17.TransporterAclmowledgmeat of Receipt of Materials _ <br /> Transporter 1 PnM ypedN a t SI naNre <br /> 2 0 1 9 t� n Monts 4yD'ayw.g Yaer <br /> Q imnsporter2 PmdedRyaW Name <br /> Signature Monet 'Day Veer <br /> Y <br /> ti <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Casualty ❑Type ❑Reeltlue ❑Partial Rejectlm ❑Fall Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generale* U.S.EPA ID Number <br /> u <br /> W Facility's Phone: <br /> 18c.Signature of Attempts Faciliy(or Generator) Month Day Year <br /> H19.Hazardous Waste Report Management Method Codes Ila,,codes for hazardous vastelreaaneM,disposal,and retyping systems) <br /> 2. 3. 4. <br /> 20.Designated Faci[4 Owner or Oplintor.Ce* adon of receipt of hammous materials covered"a manifest except as noted In Item 1 B <br /> - Pdnhd4yped Name ,. Signature �- tx. l Month Day Year <br /> 1 ,a, r�'�`4-.... <br /> PA Form 8700-22(Rev.3-95) Previous editlons are obsolete. DESIGNATED FACILITY TO GENERATOR <br />