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• • <br />aewe�det nr tvee r'nr,n. -Ined for use On elite f12aIttlJ nor Later I <br />A. 13Q594. 2364 <br />Farm Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320.0684 <br />UNIFORM HAZARDOUS <br />1.. neem ID Number <br />194471 <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 003884890 JJ K <br />WASTE MANIFEST <br />1 <br />800-321-IC733 <br />5. Generators Name and Mailing Address Generator$ Site Address (if domain man malling address) <br />Central Valley Waste Service <br />133 East Turner Road <br />Lodi, CA 95240 —� <br />Generators Phone: 20¢369$274 <br />6. Transporter 1 Company Name U.S. EPAID Number <br />Z renaposer Company Name U.S. EPAID Number <br />S. oe i tiff ���OeAdOrg u.s. FP CAlTDOC <br />}�WI 17 <br />35251 Old Skyline Road <br />Kettleman City, CA 93239 <br />Fadi sPhons: 559,21 9711 <br />ge, <br />91b. U.S. DOT Description inducing Proper Shipping Name, Hazard Class, ID Number, <br />1o. Container <br />11. Total <br />12. Unit <br />10 Wada Codes <br />No. <br />Type <br />HM <br />and Pacing Group (if any)) <br />Quantity <br />WIN01, <br />1. Non•RCRA Hazardous Waste, Solid (soil Wh lead) <br />1 <br />OT <br />18 <br />Y <br />611 <br />0 <br />i <br />2. <br />w <br />C7 <br />7. <br />4 <br />14Handling udansand Additional <br />/Vear Proper cIOtNng When HandllOgo `J �la <br />eial. ,((�1 Jl-r <br />ERGffi NJA , <br />Profile *. CA298562 (soil cJra lead) <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: the by dedare that the contents; ofmis consignment are fully and accurately described above by the proper shipping name, and ars classified, packaged, <br />marked and labeledlplanmed, and era in all res in proper condition for transport according to applicable Interregional and natimal govemmental regulations. If export shipment and I am the Primary <br />Exporter, I ceNty that the contents of this tong ent conform to the tenns of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statem entified in 40 CFR 262.17(a) (it I am a large quantity generator) or (b) (ifI am a small quantiy generator) is true. <br />erems, erors Pdntedrryped Name Signature 'Manor ,a� Year <br />16. Inte ,' Sn ❑ <br />Import to U. S. ❑F.port hen .S. Part of englexiC <br />F <br />= <br />Transporter signature(for exports dNy): Dale leaving U.S.: <br />17. Transposer Acknowledgment of Receipt of Materials <br />F" <br />Tzar' at ry1 PrIpWirped Name Signa Month Day Year <br />2 <br />�t <br />-LW IKa <br />2 <br />Transported 2 PmtedrTyped Name - Signature Monih Day Year <br />cc <br />r <br />18. Discrepancy <br />I <br />16a. Discrepancy Indication Spam ❑ Quantity ❑ T� El Re". El NOW Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Faddy (or Generator) U.S. EPAID Number <br />J <br />V <br />LL <br />Fadiys Phone: <br />w <br />IS, Signawmof Alemate Facilily(or Generator) <br />Monro Day Year <br />Q <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazus ardowaste "anent, disposal, and recydirrg Systems) <br />7. <br />d. <br />20. Designated Fad/lliityy Owner or Operator Cermiatlon of receipt of hazamrna materials covered M the mannites[ except as noted in Item Ifla <br />PsntedRYPed� ,/�/� R, SignaNre� <br />yQy'jaD <br />O <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320.0684 <br />