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• <br />F d ' had for use on elite (12- itch) <br />DT(. 00596. '£690 <br />Fonn Approved. OMB No. 2050-0039 <br />,nese. <br />EPA <br />int or type.( OMasrg P •,.•••••••-•� <br />1. Generator IO Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />a. ManHast Tacking Number <br />UNIFORM HAZARDOUS <br />00388 4 910 JJ K <br />WASTE MANIFEST J CALOMISU71 <br />1 <br />1300-321.113M <br />5. Generators Name and Mailing Address GeneraWfs Site Address (if different Nan mailing address) <br />Central Valley Waste SeMCe <br />133 East Turner Road <br />Lodi, CA 952AO <br />Geneatols Phone: 209-3693274 <br />6. Transporter 1 Company Name U, S. EPA ID Number <br />L poo <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />ber <br />8. DeLT1en11C�1 Ntl3512 all 111 U.S. EPA CIANumTWD346117 <br />35251 Old Skyline Road <br />Kettleman City, CA 93239 <br />Facilil Is Phone: 559- 11 <br />ga, <br />9D. U.S. DOT Description (including Proper Shipping Name, Harard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group Cd any)) <br />Quantity <br />WLNc4. <br />1. NOIHRCRA Hazardous Waste, Solid (6011 with lead) <br />1 <br />DT <br />1a <br />Y <br />611 <br />z <br />0 <br />z <br />Z. <br />w <br />3. <br />4. - <br />pedal Handling Instructions and Additional Infonoaban <br />Wear Proper Clothing When Handling Mal al. <br />i;. NIA <br />ERG i J <br />Ri3ule n'. 0:.2 562 (soll CAV toad)) <br />m mat the contents of this consignment am fully and accurately descnbed above by the paper shipping name, and as classified, packaged, <br />1S. GENERATOR'SIOFFEROR'S CERTIFICATION: InereY4O <br />marked and abeledlplaraaed, and are to all respects incondition for transport according to applicable international and national gwemmental regulations. If export shipment and I am the Primary <br />Exporter, Icertify that the conlenLa of this consignment co the terms of the allched EPAAcknoWedgmenl of Consent <br />I certify that the waste minimization sUlement NentifiedR 262.27(a)jit l ama large quantity genemtor)or(b) Ifdl am a small quantirygeneator)is he. <br />Geneatoe Rerofs ri tedfryped erne Signature Month Day Year <br />v � <br />3a111(31- <br />I Intemational Shipaints <br />port to U.S. Expos from .S. Pod of entrylent: <br />_z; <br />p_ <br />Tans naMa fore y): Data leafing U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials PC <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />a <br />Y��Z-J�`r ti _ <br />QTransporter <br />2 PrinlecifTyped Name n re Month Day Year <br />K <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />- <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />FaWilys Phone: <br />w <br />18c. Signature ofARemate Facility(or Generator) <br />Monm Day Year <br />4 <br />2 <br />GO <br />19. hazardous Wass Report Management Method Coda (i.e., mdesfor hazardous waste "event disposal, and recyclingsystems) <br />2. <br />20. Designated Facility Owner at Opeator. Certfication of receipt or haallous materials covered by the manifest except as noted 4 Item <br />Pnnledfryped Na Signature ^ Month Day Ye <br />/I 14-7 v I. <br />EPA Form 8700-22(Rev. 3-05) Pres editions are obsolete. DESIGNATED FACI ATION STATE (IF REQUIRED) <br />10321.0209 1 <br />