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9 <br />Please faint or Noe. IForm desioned for use on elite (12-oitch) NDewriter.) <br />p�r_- 0(1596.1 lN1z <br />Forth Approved. OMB No. 2050-0039 <br />EPA Form 8700-22(Rev.3-05) reviouseditionsareobsolete. DESIGNATED FA l ITYTO DESTINATION STATE (IF REQUIRED) <br />10321.0201 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tacking Number <br />WASTE MANIFEST I <br />CAL000194471 <br />1 <br />800-321-1030 <br />1 003884902 JJ K <br />S. Generators Name and Mailing Address Generators Site Address (if different Nan mailing address) <br />Central Valley Waste Service <br />133 East Turner Road <br />Lodl, CA 95240 <br />Generators Phone: 209-274 <br />6. Trans her mpany Name <br />U.S. EPA ID Number <br />C <br />7. Transport 2 Company Name <br />U.S. EPA IO Number <br />8. De��Nl�o �Od�itaMdre <br />U.S. EPA ID Number <br />35251 Old Skyline Road <br />CATUO0645117 <br />Kettleman City, CA 93239 <br />Facility's Phone: 559-311 <br />is. <br />91b. U.S. DOT Description (including Proper Shipping Name, Hall Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />1J. Waste Codes <br />No. <br />Typo <br />HM <br />and Paddn Group g an <br />9 D( YIl <br />Cul ty <br />Wt Nd. <br />I. Non-RCRA Hazardous Waste, Solid (soli with lead) <br />1 <br />DT <br />18 <br />Y <br />511 <br />0 <br />Z <br />2. <br />w <br />c7 <br />3. <br />4. <br />14 Svedal Handling Instructions and Additional tnnae <br />fanon <br />Wear Proper Clothing When Handling Materlal. <br />ERG A N/A <br />Pronto # CA2— Z-1 (-oil CAI leap <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby tadara that the contents of this consign l are fully and accurately described above by the proper shipping name, and are <br />dassified, packaged, <br />marked and labelecilplararded. and are in all respells In proper condition for transport according to applicable international and national governmental <br />regulations. If expert shipment and <br />I am the Primary <br />Exporter, I Partly that the contents of this consignment conform to the terms of the allached EPA Acknowledgment of Consent. <br />I cartly that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is we. <br />GeneretofslOBerersPtlnt do ped Name Signature <br />Moth Day AYea�r <br />F <br />I6. International Shipments <br />11 Import to U.S. ❑ Export from U.S. Pan of anal <br />Z <br />Transporter signature (for exports only): Date leaving LLS.: <br />W <br />ci l 17. Transporter ArknoWedgment of Reof Materials <br />Transporter I Pnnle ad Name Signature <br />Month Day Year <br />O <br />12. <br />^ J Z <br />z <br />Qw <br />Transporter 2 PdntedRyped Name Signal <br />Monro Day Year <br />oc <br />H <br />18. Discrepancy <br />IBa. Discrepancy Indication Space ❑ Quantity El Type El Residue <br />❑ Partial Rejection <br />❑Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility for Generator) <br />U.S. EPA to Number <br />J <br />U <br />LL <br />Facllily's Phone: <br />w <br />18c. Signature ofNtemate Facility (or Generator) <br />Month Day Year <br />Q <br />2 <br />IDN <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hauNous waste treatment, disposal, and recycling systems) <br />coo <br />,. � � <br />2. <br />3. <br />4, <br />20. Designated Facility Owner or Operator CaNB 'on of receipt of harardous materials covered by the manifest except as noted in Item t <br />PdoteNT me , $ignawra <br />MwN Day Year <br />n <br />EPA Form 8700-22(Rev.3-05) reviouseditionsareobsolete. DESIGNATED FA l ITYTO DESTINATION STATE (IF REQUIRED) <br />10321.0201 <br />