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0 <br />plemenrintnr Nna !Fano desianAd for use do elite 112-oitchl ypawnter.) <br />Disc. 00596. 1693 <br />Form Approved. OMB No. 205UO39 <br />EPA Form 8700-22 (R€v:10S) Prevrous#11ons are obsolete. ° U -Awn <br />QEsmATEu(F�' TO DESTINATION STATE (IF REQUIRED) <br />10321.0212 v <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phoneanifest <br />- <br />Tracking Number <br />JJ K <br />WASTE MANIFEST CAd.000194471 <br />t <br />800321-1=7003884914 <br />S. Generators Name and Mailing Address Generators Site address (if different than mailing address) <br />Central valley waste SeMCe <br />133 East Turner Road <br />Lodi, CA 95240 <br />Generators Phone: 2043848274 <br />6. Transporter I Company Name <br />T5 <br />U.S. EPA 10 Null <br />�%xx, v <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />a. De '� i � p frtdnl m¢tR <br />U.S. EPA ID Number <br />35251 old SKyllne Road <br />CATUOCU5117 <br />Kettlernan City, CA 933239 <br />Faaliys Phone: 559386-9711 <br />9a. <br />9b. US. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13 Waste <br />Codes <br />No, <br />Type <br />HM <br />and Paclaang Group if any)) <br />Ouantity <br />WtNol. <br />1. Non-RCRA Ha2ardouswaste, Solid (soilvMn lead) <br />t <br />0T <br />18 <br />v <br />6" <br />0 <br />w <br />z <br />2. <br />w <br />t7 <br />3. <br />4. <br />14. Se a <br />cur roper Cln tiingnj len Ha �ola9 6latedal. <br />R R NIA <br />reme s CADOReco rano encu 1ev <br />... _ _ s._.. _....._ <br />5 GENERATOR'SIOFFEROR'S CERTIFICATI : I hereby declare that the contents of this consignment are fully and accurately desoibed above by the proper shipping name, and aro classified, mcWged, <br />marked and Iabelecuplacarded, and are in a specis in proper condit on for transport according to applicable intamationaland national governmental regulators, If export shipment and I am the Primary <br />Exporar, I certifythat the conic ; of thi signment conform to the terms of the attached EPAAckmWedgment of Consent <br />I cerbly that the waste minimization emend identified in 40 CFR 26Z27(a)(41 am a large quantity generator) or (b) (if I am a small quantity generator)is we. <br />Gpner Olferafs Printedlr_.Vitalliame sgnawre <br />Month <br />Day Year <br />'�'o <br />J <br />F— <br />15. International Shipments <br />❑Import to U.S. ❑Export mU.S. Pon of antrylexil: <br />Tmnspoder signawre (for expans only):. Date leaving U.S.: <br />w <br />17. Transporter AdaoWedgmenl of Receipt of Materials " <br />Tmnspo 1 PdnteMypetl Name11 /� - Si core <br />Month <br />Day Year <br />y <br />KJ� K+�V <br />13-o I dY <br />2Q <br />Tmnspaner2Printearryped ame sivium <br />Month <br />Day Year <br />K <br />r <br />18. Discrepancy <br />19a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue <br />❑Partial Rejeaan ❑ull <br />Rejectlon <br />Manifest Reference Number <br />Z <br />18b. Alternate Faulity(or Generator) <br />U.S. EPA 10 Number <br />J <br />V <br />u <br />Fadliys Phone: <br />w <br />18c. Signature ofAlumate Fadliy(or Generator) <br />Month <br />Day Year <br />Q <br />2 <br />a—i <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />� <br />,. � ^ <br />2. 3. <br />4. <br />20. Designated Facility Owner of Operator:Certificationof receipt ofNous materials covered by the manifest except as nded in Item l8 <br />—� <br />PdntKFyped Nam Signa <br />Monti <br />Year <br />O <br />n <br />EPA Form 8700-22 (R€v:10S) Prevrous#11ons are obsolete. ° U -Awn <br />QEsmATEu(F�' TO DESTINATION STATE (IF REQUIRED) <br />10321.0212 v <br />