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• <br />O.T.'Z. 00.804 <br />0.42',} <br />Forth ADDroved. OMB No, 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. / / DEb9G`NATED F4911C1Y TO DESTINATION STATE.(IF REQUIRED) <br />I 10326.1877 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />I <br />2. Page 1 of <br />I 1 <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 003766589 JJK <br />WASTE MANIFEST <br />5. Generators Name and Mailing AddreG'A 4Q 14;14 <br />ss Generators Sia rens (if different than mailing address) <br />CENTRAL VALLEY WASTE SERVICES INC. 1393 EAST TURNER ROAD <br />P.O. BOX 241001 - LODI, CA 95240 <br />A 95240 <br />GeneratorLODI.s PCM1one'. <br />aa <br />6. Transposer 1 Company arae U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA 10 Number <br />DEMENNO/KERDOON CATDSD013352 <br />2000 ALAMEDA STREET <br />ppNO�RTH <br />CA 90222 <br />Fas'Plwnd'.N, <br />ai <br />9a. <br />9b. U.S. DO CescdptWn(nduding Proper Shipping Name, Hazard Class, IDNumber, <br />10.Containers11.Total <br />12. Unit <br />13.Wasle Codes <br />No. <br />Type <br />HM <br />and Packing Group lir any)) <br />Quantity <br />Wt.Nol. <br />1. <br />F <br />WASTE FLAMMABLE LIQUID, N.O.S., 3, UN1993 PGII (PETROLEUM <br />M/ <br />DM <br />G <br />DISTILLATES) <br />1/t/ <br />z <br />2. <br />w <br />4. <br />14. Special Handling Inslmcsons and Addifional Information <br />THINNERS)PANT MD(ED FLAMMABLE PRODUCT <br />WEAR GLOVES AND EYE PROTECTION. 24 EMERGENCY CHEMTREC 800424-M AND CHICO ORAN OIL SERVICE X733-9043 <br />15. GENERATOR'SfOFFEROR'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 rational govemmental regulations. If export shipment and I am the Primary <br />Exporter, I cedrcy, that the contents of this consignment oonforrn to the terms of the attached EPA AcknavAedgment of Consent - <br />I carr(, Nat the Waste minimizafion statement identified in 40 CFR 262.27(a) (if I am a large quantly generator) or (b) (11 am a small quentiry generator) is we. <br />GeneratorOfferors <br />Pdnted4yped Name Sign re;, .MLonty Day Vear <br />'e-VNV-L� n. u G <br />_J <br />r <br />16. International Shipments <br />❑ Impart to U.S. ❑ Export from U.S. P4 of entr iC <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Psflyped ntedName Signet Monty Day Year <br />a <br />/9%' Q / <br />Z <br />Transpcser2 PdnledRyped Name Signi Monty Day Year <br />oc <br />1- <br />18. Discrepancy <br />?8a. Discrepancy Indication Spars ❑ Quantity ❑ Type ❑ Residue ❑ Pwi al 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 />Facllitys Phone: <br />18c. Signature W Altemate Facility (or Generator) <br />Month Day Year <br />aW <br />to <br />H19. <br />Hazardous Waste Report Management Method Codes(i.a., codes for hazardous waste treatment disposal, and recycling systems) <br />7. <br />2. 3. <br />4. <br />. Designated <br />kai Omer or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Ito <br />1 <br />P ted/typed Name , / Signature n Oay ar <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. / / DEb9G`NATED F4911C1Y TO DESTINATION STATE.(IF REQUIRED) <br />I 10326.1877 <br />