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0 <br />nr hma tpnpn daannad far use nn Alto (12 -pitch) Noa vatted <br />A. OBS94. 2351 <br />ForrnAcoroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320.0671 <br />fm <br />UNIFORM HAZARDOUS 1. Generator 10 Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracltlng Number <br />003884886 JJ K <br />WASTE MANIFEST CA,L000194471 <br />1 <br />aw-321-ta30 <br />5. Generators Name and Mailing Address Generators Site Address (it imminent titan mailing address) <br />- <br />cefRrdl Valley Wavle Sell <br />133 E361 TUmer Road <br />Lodi, CA 95240 <br />Ganerators Phone: 209'369-6274 <br />6. Tn)T'J r1¢gnp4n M <br />U. mbar <br />7. Transporter 2�Coo Company Name <br />U.S. EPA 0 Number <br />S. Degm{pk9uP9gU'itlgT@ a})gBtieR <br />U.S. EPAIDANumber 46 117 <br />C 7170 <br />35251 Old Skyline Road <br />Ketteman City, CA 93239 <br />559-386.9711 <br />Foolft Is Phone: <br />go. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hanrd Class, ID Number, <br />10, Contalnen <br />11. Total <br />12. UNI <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Paddng Cmup(If al <br />Quantity <br />WGVOI. <br />1. ort• v , azar OU6 Wave. Solid ED ea <br />1 <br />OT <br />18 <br />Y <br />611 <br />0 <br />i <br />2 <br />w <br />7. <br />GIG�U�9zS7 �� <br />4. <br />14. SV, "*Fsk- , dn6Q4N f WJW9S44�S , e eDal. <br />E X N7 <br />Pro 7P. CA298552 (Son Wall lead <br />15. NERATOR'SIOFFEROR'S CERTIFICATION: I hero eciare that me contents of this consignment are fully and accurately described above by the proper shipping name, am are <br />dassil packaged, <br />marked and Iabeled/Dlacartlegend are in all respects in per condition for transport according M applicable imemationaland national governmental regulations. If export shipment and I am the Primary <br />&pMer,lceraty NatNecontents of Nis mnsignmen form bNeterms afros attached EPAACWpwledgment of Cansenl <br />certity mat me waste minimization statement idea' in d0 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Gen retardes Pdnted7Ty d ams Signature <br />Ml Day Year <br />3 0 ori` <br />F <br />16. nrem onalblmrsnents Import to U.S. - ❑&POO fran U.S. Port of entryfaxit <br />= <br />T its only): Date leaving U.S.: <br />W <br />17. TransponcrAdmorEedgment of Receipt or Materials <br />O <br />Nam .e <br />T Oar ypedIlls <br />Mo Y <br />a <br />QT <br />spater2 n TypW Name Signature <br />Month Day Year <br />z <br />r <br />16. Discrepancy <br />I <br />lea. 0isaepancy Indication Spare ❑ Quantity ElType❑ Residue <br />ElPartialRejection <br />❑ Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (in Generator) <br />U.S. EPA ID Number <br />J <br />V <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Fadlity(or Generator) <br />Month Day Year <br />6 <br />2 <br />19. Hazardous Waste Report Management Method Codes Ila, codes lur hazardous waste nature nl, disposal, and recycling systems) <br />0 <br />1. I !1 <br />2 1. <br />Z8. Designated Facility Owner or Operator. Certification of receipt of hazardous materials mverw by the manrfest except as acted in Item 18a <br />Primed yped NaO r� Signature fe;I\ <br />a� o <br />J <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320.0671 <br />fm <br />