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ou,...e .d�l,.r e�,.e ICnrm irndnmd(nr uco nn nlilo It 9_ni4hl hm. <br />p• .. <br />G)1.596. £69' <br />Forrn Approved. OMB No. 2050-0039 <br />EPA Form 870022 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATIOPtSTATE-(IF REQUIRED) <br />10321.0216 <br />UNIFORM HAZARDOUS 1 1. Generator 10 Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />d. Manifest Tracking Number <br />1 003884918 JJ K <br />WASTE MANIFEST CA=Ig4471 <br />1 <br />W0 -321 -IOM <br />5. Generators Name and Meiline Address Generators Site Addras9('ddifierani man mailing address) <br />Central Valley Waste Sei <br />133 East Turner Road <br />Lodi, CA 95240 <br />Generators Phone: 204369$274 <br />6. Transporter 1 Company Name U.S. EPA ID Nu <br />CW. (1333/ <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />ID Number <br />8.De �� iv��ab�p da�ueAddrel U.S. EPACAICC05ZI 17 <br />35251 Old Skyline Road <br />Kettleman City, CA W239 <br />Facility's Phone: 550,,38&9711 <br />9, <br />9b. LLS. DOT Description (including Proper 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 Padding Group (if any)) <br />Quantity <br />Wtivol. <br />z <br />T Non-RCRA Hazardous Waste, Solid (soil rAh lead) <br />1 <br />OT <br />16 <br />Y <br />611 <br />0 <br />gra <br />z <br />2. <br />LJ <br />CD <br />7. <br />d, <br />Handling InsWctons and Additional Information <br />7tial <br />Wea! Proper Clotning When Handling Maters . <br />ERG A Ni <br />P.ro. a A. CA' .,52 (soil CM lead) <br />v b me ro shi name ab are classified packaged, <br />15. GENERATOR'SIOFFEROR'SCERTIFICATIOVhe4bydare that the contents of this consignment an fully and accurately described aboey p per ppug ,pa g , <br />marked and labeledlplacarded, and are in all aer condition far transport according to applicable lntemationaland national governmental regulations. If export shipment and l am the Primary <br />Exporter, I costly that the contents of Uis consm to the terms of the attached EPAAcknovdedgment of Consent <br />I ceNy that me waste mmimiution statementCFR 21 if am a large quantity generator) or (b) (ifI am a small quantity generator) is we. <br />n alofs;Ofl fs PrntedlT ped Name <br />Signature MonthDay Year <br />1.- <br />16. International Shipments ❑ Import to U.S. ❑ &p am US. Pod of entrym iC <br />Transporter signature (for exports only): - Date leaving U, S.: <br />K <br />Ulu <br />17, Transporar Acknv.Medgmem of Receipt of Materials <br />K <br />Transporter 1 Parisi _/ Signal Qay O� <br />on, <br />Transporter 2 Prntadlryped Name Si re Month Day Year <br />K <br />r <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouarmy ❑TYPa ❑PartialR ❑ j <br />❑Residue ejection Full Rejection <br />Manifest Reference Number, <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />tai <br />Facility's Phone: <br />w <br />18c.Signature of Alternate Faculty (or Generator) <br />Meom Day Year <br />6 <br />Z <br />19. MaraNeus Waste Report Management Method Codes (i.e., codes for hazardouswaste treatment, disposal, and recycling systems) <br />0 <br />1 41 � iry <br />2. 7. <br />d. <br />20. Designated Facility owner or Operator.. Certification ofn ipt of hazardous malerals covered by the manifest except as noted in item 1 B <br />Ptinledlryped Name ff )t riuo'— R Ci Sigrowrs 16516`1 `1 ]e <br />EPA Form 870022 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATIOPtSTATE-(IF REQUIRED) <br />10321.0216 <br />