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Ile -ase print or type. (Formdesignod for use on elite (12-pitch)tter.) <br />• Farm Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Presous editions are obsolete. <br />�� DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2.Pagelof <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />1 CAL000194471 <br />1 <br />866-333-9222 <br />003447440 FLE <br />5. Generators Name and Mailing Address Generator's Site Address Cif different than mailing address) <br />Central Valley Waste Services Inc <br />1333 E Turner Rd. <br />Lodi, Cas- 95240 <br />Geneators Phone: ?aD �3i-Afi11 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport C=000070540 <br />7. Tramprorl Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address qNEwt U.S. EPA ID Number <br />.li L4 L rwrf}tTB Mnn14GE.q 5n1 T <br />z <br />3S�s1 ole v ayo-c PFo..A <br />1ZA44(e. d^ c:1 -r 0006 <br />eA 173 z3g y CQr,.��� 611'7 <br />r <br />Fadlitys Phone SS -3 - 9 i 7 <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contamsm <br />11. Total <br />12. Unit <br />HM <br />and Paddng Group (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />No. <br />Type <br />1. Hon BCRA Hsardous Waste Solid (Motor Oil tm <br />a <br />352 <br />o <br />Inorganic Absorbent) <br />D� <br />qoo <br />i <br />P <br />z <br />2. <br />W <br />x! <br />3. <br />4. <br />A <br />14. Wal Handel IO n Ihl sen itional Information <br />IS1 <br />�.��tF- <br />Project Humber: CV01661 <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 labeledlplacarded, and are in all respects in propercondtlon fortransportaccording to applicable international and national governmental regula5ans. If exportshipment and I am the Primary <br />Exporter, I certify that the contents of this consignment contain to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement kens in 40 CFR 262.27(x) (g I am a large quantity generator) or (b) (if I am a small quantity generator) is We. <br />GeraintorsiCrIffermis PininfedlTyped Name Month Uay Year <br />`/O <o <br />_J <br />z <br />16. In national Shipments❑PxpoM1o <br />`` El Import to U.S. frmU PoM1of entry/exit <br />Trans iter signature Ifor exports only): Date leaving U.S.: <br />W17.TransporterAcknowledgmentof <br />Receiptof Materials <br />Trans iter Pnntedilyped Na Signer on ay Year <br />N <br />�J�l�d M � z� ,a <br />�on <br />a <br />Transporter 2 Printed/Typed Name Signature Day ear <br />fix <br />F <br />} <br />18. Discrepancy <br />I <br />18a. Disaepancy Indication Space ElOuanti ty Type ❑Residue L1PaNal Rejection Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />a <br />ri <br />Facil' s Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />a <br />U, <br />19. Hazardous W st Re ort Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. - <br />2. 3. <br />4. <br />�0..Dei Faciti er or Opera( r: Certification of receipt of hazardous materials covered by the cept s noted in Item 18a <br />Sig re <br />on .pay- <br />Yew <br />EPA Form 8700-22 (Rev. 3-05) Presous editions are obsolete. <br />�� DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />