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A <br />elite 112 itch! rvn vyrifer 1 <br />0 <br />n"SC.. 13(5594. 2376 <br />Fan Approved. OMB No. 205M039 <br />EPA Form 8700-22 (Rev. 3-05) Pr are ere. DESIGNATED FACILQY TO DESTINATION STATE (IF REQUIRED) <br />10320.0696 <br />UNIFORM HAZARDOUS 1. relator ID Number <br />2. Page i of <br />t"32t <br />3. Emergency Response Pnone <br />10� <br />4. ManReet rocking Number <br />0 0 3884898 <br />JJ K <br />WASTE MANIFEST CA1D00194471 <br />S. Ge 7ernr N raj and.Myling AddresgCe Generatoh Site Address (if different than <br />� mi 5 Caney wa612 S r2 <br />riming address) <br />133 East Turner Road <br />Lodl, CA 96240 <br />Generators Phone: 209-36943274 <br />B. Transporter f Company Name <br />U.S. EPA IO Number y/ <br />4%,f- <br />% <br />7. Tmnspo r 2 Company Name <br />7. <br />U.S. EPA ID Number <br />8. Dtt ffiffl.aff MddrR*i)ie°lf <br />U.S. EPCANuTTA70646117 <br />35251 Old Skyline Road <br />Kettlernan City, CA 93239 <br />Fadlitys Phone: 559`36-9711 <br />9a. <br />911 U.S. DOT Description (including Paper 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 Padtirg Group(H any)) <br />Quantity <br />Wt.Nol. <br />f. Non-RCRA Hazardous Waste, Solid (soil with lead) <br />1 <br />OT <br />18 <br />Y <br />611 <br />K <br />O <br />i <br />2. <br />w <br />a0 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Info rnaton <br />Wear Proper Clothing when Handling Material. <br />ERG#. NIA <br />Profile # CA29BS62 (soil clay lead) <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that he contents of his consignment are fully and a=rately described above <br />by the proper shipping name, and am dassifila <br />.packaged. <br />marked and Iabeled/pecarded, and are in all respects in proper condition for transport according to applicable intematlanal and national governmental regulations. If export shipment and I am he <br />Primary <br />Exporter, I cortiby that he contents of this consignment conform to he terms of he attached EPAAcknowledgment of Consent <br />I comfy that he waste minimization statement identified in 40 CFR 281 (if I am a large quantity generator) or (b) (if I am a smal quantity generator) is We. <br />Ge retors`Off Mrs Prim ped Name Signature <br />V; <br />Month <br />Day Year <br />J <br />16. International shipments <br />1-1 Impart to U.S. ❑Export oro U. S. Pat of enlryledt <br />= <br />Transporter signature(for exports onty): Date leaving U.S: <br />K <br />11. Transporter Acknowledgment of Receipt of Materials <br />w <br />Transporter 1 Printedfryped Name Signatu <br />Month <br />Day Year <br />OIL o <br />J <br />QTransporter <br />2 Fdnl yped Name S Nre <br />Monh <br />Oay Year <br />K <br />r <br />♦ <br />18. Disaepan— <br />1 Be. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />.. . <br />❑ Partial Rejection ❑ <br />Full Rejection <br />Manliest Reference Number <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />_ <br />U <br />LL <br />Facility's Phone: <br />�- <br />Month <br />Day Year <br />W <br />18c. Signature ofAmmale Fauuty(or Generator) <br />6 <br />Z <br />xziz <br />19. Hazardous Waste Report Management Method Codes (i e., codes for hazardous waste treatment, disposal, and regtlug systems) <br />20. Designated Faclity OwnerorOpempr.. Certificalion of mi hazardous matenalscovered by he marl except as noted in Item 182 <br />Prudedzryped Nam Signature _ <br />Moth <br />Day Yea <br />EPA Form 8700-22 (Rev. 3-05) Pr are ere. DESIGNATED FACILQY TO DESTINATION STATE (IF REQUIRED) <br />10320.0696 <br />