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Pfease pent or type. (Form designed for use on elite 112-bitcht wntar 1 �� `i �, v1 • <br />EFA Form 8700-22 (K6v. 3-65) rrevious editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />- - - + 1 1 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page i of 3. Emergency Response Phone <br />Form v.pproved. UM9 No. 2050-0039 <br />4. Manifest Tracking Number <br />WASTE MANIFEST CAL0001941471 1 866-333-9222 <br />1 <br />0 0 3 4 47220 FLE <br />5 GeratoCs Na a rMnaa��I Addr Ge S' A� ass �rfdithere0{,Na nmailin address <br />g ) <br />mtza� vol%I haste Services Inc 'b" 7Vsaer <br />¢d <br />PO ]Doe 241001 Lodi, Ca. 95240 <br />Lodi, Ca. 95241 <br />Generators Phone: ?no 911Scott <br />6. ransponer I CompanyName <br />U.S. EPA ID Number <br />Adratracad Chewical 1xalasport <br />CAR000070540 <br />7, Transporter 2 Company Na <br />Gam-• � gr� �r S �,• S ;,� <br />U.S. EPA ID Number <br />� v.,,� <br />� 03 G 2-kk o <br />6. D mated Fac Na a and Site Ad a <br />dean Joso, LLC (San Jose Bacilit7) <br />U.S. EPA 10 Number <br />1021 6erzyessa Road <br />azzyozs Road <br />San Jose, CA 95133 <br />Facili sPhone: 408-441-0962 <br />CAD059494310 <br />ga, <br />9b. U.S. OOT Desorption (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Comet ea <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nd. <br />13, Waste Coda <br />No. <br />Type <br />z <br />1, , as ! a , , , Ra kDOUT) <br />iLIN <br />300P <br />w <br />z <br />O <br />2. <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information <br />1) ERG E: 128; C111322832; CEC-rX7l Q_X J* ERGl128 <br />2) <br />( z ) ERG#128; ERG #: 128 <br />Project Number: �B4MB•9a�(01379_ <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cornsgnment are fully and acaatety described above by the proper shlppkg name, and are classified, packaged, <br />marked and IahefeNplacarded, and are in all respects In proper condition for transport according to applicable international and national governmental agulatlons. If export shipment and I am the Primary <br />Exporter, I certify that the contents of NA consignment conform to the terns of the alteched EPA Acknowledgment of Consent. <br />I certify that this waste minimization statement identifbd 1140 CFR 26227(a) (t I am a large Quantity generator) or (b) (if I am a small quantity generator) <br />is true. <br />erierat s n ams igna <br />i <br />ay ear <br />I <br />16. Interna Shipments 1:1 Import to U.S. F-1 Export from U.S. Port of anbylexib <br />= <br />Transporter signature lor exports only): Date leavirg U.S.: <br />w <br />17. Transports -Acknowledgment N Recegt of Mwadals <br />Transposer 1 Print yped Name igMonth <br />Day Year - <br />0 <br />a <br />q <br />C <br />QTans <br />or t Foram Rypetl Name <br />Year <br />1Day <br />Discrepancy <br />j18. <br />18a. Discrepancy Indication Space ❑ oui n ity ❑ Type ❑ Residue <br />❑ Penial Rejection ❑ Full Rejection <br />Manifest <br />Manifest Reference Number. <br />Z <br />18h. Alternate Facility for Generator) <br />EPA ID Number <br />J <br />U <br />a <br />LL <br />Facilitys Phoma: <br />w <br />18c. Signature ofAlremate Facility (or Generator) <br />Month Day year <br />a <br />Z <br />y19. <br />Hazardous Waste Repod Management Method Codes (I. a., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1 �\ \ S <br />2 3, <br />4, <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br />Pnnted/fyped a nature <br />(� \�� <br />\ \ln��• <br />fdpON Day Year <br />.,� QV 1 l3 <br />EFA Form 8700-22 (K6v. 3-65) rrevious editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />