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Please print or type. (Form designed for use on elite (12-pitch)typewriter.) <br />• Farm Approved. OMB No. 2050-0039 <br />EPA Form 8760-22 (Rev. 3-05) P-revious editions are obsolete. <br />0 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator 10 Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CALOOD194471 <br />1 <br />860-785-7226 <br />1 003931454 FLE <br />5. Generators Name and Mailing Address Generator's Site Address (If different than mailing address) <br />Central Valley taste Services Inc <br />1333 E Turner Rd. <br />Lodi, Ca- 95240 <br />Generators Phone: 2fkQ ilR—SfiYi <br />6. Transporter 1 Company Nam U.S. EPA ID Number <br />Advanced Chemical Transport CAR000070540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Chemical Waste Management <br />35251 Old Skyline Road <br />Kettleman City, CA 93239 <br />Facility's Phone: 559-386-9711 CAT000646117 <br />as. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hai Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt Not. <br />O <br />1 Hon HCBA Hazardous Taste, Solid (Oily Solids) <br />B <br />............................. <br />i <br />i <br />3. <br />4. <br />...... _.. _.. <br />1 <br />L.. _ _.,. _.... <br />( <br />14. Special Handling Instructions and Additional Information <br />1) CA600162; CEC- <br />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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulators. If exparl 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 partly that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or ) (if I am a small quantity g stator) is we. <br />Generato slCffxt s Print ypea Na igna ure <br />on ay ear <br />ON <br />1v,, <br />.r <br />F <br />16.ntemational Shipments <br />❑Importto U.S. ElE Expert U.S. Pori of en lexit: <br />xpo by <br />z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. TransporWAcknowledgment of Receipt of Materials <br />itunDay <br />YearTover Pdnte yped Name gn <br />a <br />r an �na <br />e i <br />GTransporter <br />Print/Typed Name signature Month Day Year <br />C <br />18. Discrepancy <br />I <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue j ❑ j <br />❑Portal Rejection Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />Facility's Phone: <br />w <br />111c. Signature ofAltemate Facility (or Generator) Month Day Year <br />zz <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />3. <br />4. <br />20. D Facility Own Aerator. Certification of receipt of hazardous materials covered by the manifes noted <br />PdntedyI araeSi atu t y <br />/ <br />Y ar <br />EPA Form 8760-22 (Rev. 3-05) P-revious editions are obsolete. <br />0 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />