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Please print or type. (Farm designed for use on elite (12-ititchIP riter.l <br />• Form Annrnved OMR Nn 2mn-nn3g <br />EPA Form 11700-2227ev.T-05) Previous e7ittions are obsolete. <br />l D551GNAT ED FACILITY TO DEST INATO N­�TATE (IF REQUIRF0) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of3. <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CAL000194471 <br />1 <br />1 <br />888-785-7225 <br />003931373 FLE <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Central Valley Waste Services Inc <br />1333 E Turner &d. <br />Lodi, Ce_ 95240 <br />Generators Phone: 709 333-5677 <br />6. Transporter 1 Company Name U.S. EPAID Number <br />Advanced Chemical Trans ort 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 />Hettleman City, CA 93239 <br />Facility's Phone: -g CAT000646111 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt N01. <br />13. Waste Codes <br />No. <br />Type <br />o <br />1. Hon SCIIA Hazardous Waste, Solid (Oily Solids) <br />^ <br />352 <br />j <br />t <br />Z <br />Z. <br />W <br />I <br />3. <br />4. <br />) i i <br />i <br />14. Special Handling Instructors and Additional Information r <br />1) CA600162; CEC- DDI — Do3 <br />Project Humher: CV02612-02 <br />15, GENERATOR'S/OFFEROR'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 regulations. If export shipment and I am the Primary <br />Exporter, I rarity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I tardy 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 />Printedi Nameign ure on ay <br />Vtoes)Offieroes <br />it loll 01<6 1 <br />z <br />1 . International Shipments <br />❑Impartto U.S. ❑Export from U.S. Part of entry/exit <br />Transporter signature for exports only): Date leaving U.S.: <br />our <br />17. TransporlerAcknowledgment of Receipt of Materials <br />K <br />Tran dart r ped � Name n r ort ay $ ear <br />IIt <br />Z <br />Q <br />T raped r Printed/Typed Name Signalulle Monlinay ear <br />fY <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity Type ❑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 />LL <br />Facility's Phone: <br />w <br />red. Signature of Alternate Facility(or Generator) Month Day Year <br />a <br />z <br />N19, <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />I. <br />2. 3. <br />4. <br />20 ate Fact er or Operator. Certification of receipt of hazardous materials covered by the except as noted in Item 18a <br />1 <br />Prime R N m S re nt Da <br />V r <br />EPA Form 11700-2227ev.T-05) Previous e7ittions are obsolete. <br />l D551GNAT ED FACILITY TO DEST INATO N­�TATE (IF REQUIRF0) <br />