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Please orint or Noe. (Form designed for use on elite (12-oitcht0writer.) <br />• Form Approved. OMB No. 2050-0039 <br />EPA Form 8710l 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />888-785-7225 <br />4. Manifest Tracking Number <br />FLE <br />WASTE MANIFEST =000194471 <br />1 <br />003931127 <br />5. Generators Name and Mailing Address Generators 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: 7FIQ 1141--r'a111 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport CM000070540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />S. Designated Facility Name and Site Address U.S. EPA ID Number <br />Chemical Taste Management <br />35251 Old Skyline Road <br />Kettleman City, CA 93239 <br />Facili sPhone: 559-386-9711 CAT000646117 <br />gra, <br />9b. US. DOT Descnpton(Including Proper Shipping Name, Hazard Class, ID Number, <br />10.Containem <br />11.Tmel <br />12. Unit <br />13. Waste Cedes <br />No, <br />Type <br />HM <br />and Packing Group If any)) <br />Quantity <br />WINcI. <br />1. Hon III Hazardous Taste, Solid (Oily Solids) <br />Z <br />p <br />352 <br />-- <br />— <br />o <br />0M <br />7� <br />Z <br />2. <br />W <br />C7 <br />— <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1) CA600162; CEC- <br />project Humber: <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Poly and aauately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacanded, and are in all respects in proper condition for bansport according to applicable international and 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 EPA Acknowledgment of Consent. <br />1 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 />enerato ors P' !Typed Na ignaur o ay <br />ra;r/ <br />F <br />16, Interrufficrial Shipments <br />❑ Import to U.S. LJ Export from U.S. Port of enbyleAt: <br />z <br />Trans oner si nature for exports only): Date leaving U.S.: <br />W <br />V. Transporter Acknowledgment of Receipt of Materials <br />Traysv�rt 1 PnnWffyped Na Sig ('+ !� igna n ay Year <br />s <br />l✓a <br />CL <br />G �C.49 P.a G U `l2 I <br />QTransporter <br />2 Printed/Typed Name atur onM Day ear <br />a' <br />1-- <br />♦ <br />18.Oiscrepzncy. <br />I <br />18a. Discrepancy Indication Space Ll ❑ Type ❑ Residue E] Partial Rejecdon ❑ FWI Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facili 'sPhone: <br />w <br />18c.SignatureofNam.w Fadliy (or Generator) Month Day Year <br />a <br />z <br />(D <br />19. Haarcloys Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W1, <br />2. 3. <br />4. <br />20. Dol Facility Owner ortor. Certification of receipt of hazardous materials covered by N n el as noted in Item 18a <br />Pante Name n re M th ay IT <br />EPA Form 8710l 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />