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Please print or type. (Form designed for use on elite (12-pitch)rifer.) <br />• Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (I .REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of3. <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />CAL000194471 <br />1 <br />866-333-9222 <br />003930948 FLE <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Crsatral Valley waste Services Inc <br />1333 E Yipproar Rd. <br />Lodi, Ca. 95240 <br />Generators Phone: 900 Rai iA�i <br />B. Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport CA&000070540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facilk Ve and Site Add�sage>•ent U.S. EPA ID Number <br />Chgica as e II <br />35251 Old Skyline Road <br />Rettleman City, CA 93239 - <br />Facility's Phone: 559-386-9711 CAT000646111 <br />98. <br />9b. U.S. DOT Description (inducing Proper Shipping Name, Hazard 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 />Wtivol. <br />1. ackil htL;XA 11aaarclioUS Waste, ilici (tJX.L]r o 1 <br />9 <br />�M <br />(q 00 <br />p <br />Z <br />2. <br />W <br />3. <br />4. <br />14, Special Handling Instructions and Additional Information <br />1) CA600162 ; Cl 001, aw Z Z xs$'eh. <br />project YUeber: CV02149 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedam that the contents of this consignment are fully and accurately described above by the propershipping name, and aro classified, packaged, <br />marked and IabeteNplacarded, and are in all respects in proper condition for transport according to applicable international and national govemmental 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 EPAAcknowledgmenl of Consent. <br />I ceNfy that the waste minimization statement Identified N 40 CFR 262.27(a) (If I am a large quantity generator) or (b ' m a small quandty generator) is true. <br />Generators/ 'rite Name <br />igna on sy ear <br />.24 11) <br />-1 <br />16. International iprffsntsi <br />❑ Import to U.S. ❑ Export from U.Pod of enby/exit: <br />1- <br />Transporter signature for exports onl : Date leaving U.S.: <br />w <br />17. TransporlerAckneMedgment of Receipt at Materials <br />Transpader nnted/Typed Namecc / sign '• ' / onth Day Year <br />Transporter 2 Printed/Typed Name Signature Ill Month Day Year <br />K <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity El Type El Residue ❑ Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />W <br />Facilitys Phone: <br />w <br />181 Signature ofA6emam Facility(or Generator) Month Day Year <br />Q <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (I e., codes for hazardous waste beaMent, disposal, and recycling systems) <br />1. <br />2. <br />3. <br />4. <br />.Desi ed Facility Operator: Certification of receipt of hazardous materials covered b manifes xcept em18a <br />rinR ed Name <br />Si o ay Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (I .REQUIRED) <br />