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i <br /> i. <br /> Please print or type.(Form designed for use on elite(12-pitc writer.) 41 Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL089T/ 1 209.4b0-0450 013435269 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> PACIFIC SOUTHWEST IRRIGATION <br /> 8372 S.JACKTON RD. <br /> STOCKTON.CA 95215 <br /> Generators Phone: 209.460-0450 <br /> 6.Transporter 1 Company Name US.EPA ID Number <br /> George W.Lowry,Inc. CARO00047019 li <br /> 7.Transporter 2 Company Name U.S.EPAID Number AP <br /> i <br /> 8.Desi noted Facilitlyy Name and Site Address U.S.EPA ID Number ENVIROP A <br /> �RKERSFIELD TRANSFER INC. '�.AwwcOvc�,xa HFA!TI4 nFPARTA FNT <br /> 1620 E. BRUNDAGE Ln <br /> BAKERSFIELD,CA 93907 <br /> FadlitVs Phone: 661,822-8258 <br /> 9a 9b.U.S.DOT Description[including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Padding Group clan 13.Waste Codes <br /> HM 9 pf y)) No. Type Quantity WtNol. <br /> X 1' NDN RCRA HAZARDOUS WASTE SOLID (metal grindings) I DM -30P 362 i I) <br /> I. <br /> 3. {; <br /> I <br /> I <br /> T¢¢coal Handling instructions and Additional Information <br /> �2RG#171 r4li e# �• n <br /> l <br /> USE GLOVES INVOICE#f �.SU„37 <br /> �i <br /> I,. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hembydeclare that the contents of this consignment amfullyand accuratelydescribed above bythe propershipping name,and areclassified,packaged, <br /> marked and IabelecVplamrded,and are in all respects in proper condition for transport according to applicable intemafionaland 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 EPAAcknowledgment of Consent. <br /> 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. <br /> GeneratorslOfferors Prinlecirr ed Name Signature Month Day Year <br /> S <br /> `f / S Ii <br /> w / <br /> �J 16.Intematonal Shipments <br /> r— ❑Importto U.S. ❑Export from U.S. Port of entryledl: <br /> Z Transporter signature(for exports only): Dale leaving U.S.: j <br /> w 17.TranspoderAcknowledgmenl of Receipt of Materials <br /> OTransporter)P 5teyfyped N e Signature Month Day Year <br /> a Cllln r v2 <br /> CTrensporter2 zen PrintedRyped NameSignature Monty Day Year I <br /> r I <br /> t18.Discrepancy <br /> Ise.Discrepancy Indication Space ❑ Oga.Oty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. I <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faidlitys Phone: <br /> uu l8c.Synature ofAllemale 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 /> W 2. 3. 4. <br /> O <br /> i <br /> esignated Fadlity Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Day Year <br /> I <br /> TA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> i <br />