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0 <br />please print or type. IFnrm desinned for use on elite (12 -Ditch) moewnlecl <br />CeTSC- Ct0S96- 1086 <br />Forrn 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 />10321.0205 <br />UNIFORM HAZAROOUS 1. Generator lD Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 003884906 JJ K <br />WASTE MANIFEST CALDOO194d71 <br />1 <br />8DO-321-t1T3o <br />5. Generators Name and Mailing Address Generators Site Address (if diRerenl than mailing address) <br />Central valley Wa6te Semce <br />133 Ea6t Turner Road <br />Lodi, CA 95240 <br />Generators Phone. 204369-8274 <br />6. Trampoderi mp,yName U.S. EPA ID Number <br />`71tvLr 1 q Z 0 <br />01 CQ trr w CARtraco <br />T. Transporter 2 Company Name ILS. EPA IO Number <br />B. De i � �dU�uaAddte U.S. EPA IDNumber <br />AT000646117 <br />35251 Old Skyline Ro"addC111O <br />Kettleman CRY, CA 93239 <br />Fadlitys Phone: 559-3386-9711 <br />9a <br />9b. LLS. DOT Description (including Proper Shipping Name, Hai Class, ID Number, <br />10. Containers <br />11.7otal <br />12, Unit <br />17. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNcl. <br />1 Non-RCRA Hazardous Waste, Solid (Soli With lead) <br />1 <br />OT <br />18 <br />Y <br />611 <br />K <br />0 <br />z <br />Z. <br />W <br />ED <br />3. <br />4. <br />14.5ectal Handling Instructions and Additional Information �. <br />MeaProper VottdlnU Wren Handling role enal. ! I q 2_l_J 91 <br />ERG# WA V� <br />15. RATOR'SIOFFEROR'S CERTIFIC ON: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, and are classified, packaged, <br />rked and Iabeledlplacarded, and ar all respects in patter condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />xporter, I certify that the contents is consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I cenily that the waste minimiz n statement identified in 40 CFR 262.27(a) (R I am a large quainty generator) or (b) (if I am a small quantity generator) is true. <br />Ge ratorst Brous Print ad Name SgnaWre Month Day Year <br />/ <br />P <br />is <br />16. Int ational Shipments <br />El Import to U.S. El Expan from U.S. Port of entrylext <br />Transporter signature (for exports only): Date leaving U.S.: <br />C <br />17. TmmpoderAeknovdedgmentof Receiptaf Materials <br />K <br />Transporter 1 Print Ryped Name Signature Month Day Year <br />3D <br />0 <br />I CIO <br />GTransporter <br />2 Pune yped Name SgnaWre Month Day Year <br />tr <br />} <br />ta. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Petal Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />1 Bb. Alternate Faoldy (or Generator) U.S. EPA IO Number <br />D <br />U <br />LL <br />Phone: <br />w <br />Facility's <br />lac. Signature of Xtemate Facllity(or Generator) Month Day Year <br />2 <br />h19. <br />Hazardous Waste Report Management Method Codes (i e., codes tar haramous waste eaabnenL disposal, and recycling systems) <br />0 <br />i. <br />' � /1� <br />2. 9. <br />4. <br />20. Designated Facility Owner or Opemtoc Certification of recaipl of hazardous materials memo by the manifest except as noted in Item I8a <br />PdnteNrypeN omonSgnaWre e <br />� o�rnoS yl <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10321.0205 <br />