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Please onnt or Noe. Form dasidned for use on elite 02 -pitch) Npewnter.) <br />22; - <br />Foran Approved. OMB No. 2050-0039 <br />EPA FOnn6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF=REDUFRE8�- <br />10322.2017 <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />003884934 JJ K <br />WASTE MANIFEST <br />CA1000194171 <br />1 <br />t:0.321.1OW <br />S. Generators Name and MailirgAddress Generators SibAddress(if different Nan mailing address) <br />Central Valley Wa^ote Service <br />133 East Turner Road <br />Lodi, CA 96240 <br />Generators Phone: 209.369.8274 <br />6. Transporter Company Name <br />U.S. EPA ID Number <br />QO\ i (ILS <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8.O""i jiffy a�dd�lleAddre� <br />U.S. EP 10 Number <br />3x251 Old SRyllne Road°''������ <br />Kettletnan City, CA 93239 <br />Facili sPhone: 55'f38r�9711 <br />gy <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, l0 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if airy)) <br />Quantity <br />WI.Nol. <br />1. Non-RCRA Hazardous Waste, Solid (6011 itlth lead) <br />1 <br />0T <br />IS <br />Y <br />611 <br />O <br />4a <br />W <br />3. <br />4. <br />3 O a <br />KS coriat Handling Instructions and Addibonal Information <br />Wear Proper Clothing When Handling Material. <br />ERG A N/A <br />Profile 9.. CA28562 (soil Vx lead) <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,. <br />marked and labeled/placarded, and are in all respects in proper confition for transient according to applicable international and national governmental regulations. If expert shipment and <br />I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (itI am a small quantity generator) H We. <br />GaneratoraiGfferori Printed/Typed Name Signature <br />Month Day Year <br />g / 1 bp <br />j <br />� <br />16. International Shipme <br />❑ Impon to U.S. ❑ Expon from U.S. Port o/entry/exiC <br />Transporter signature(for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transpoder 1 'ntadlryped Name nonce <br />MonN�0ay Year <br />0�C�C]_S�5 <br />L a <br />CL <br />Q< <br />Trans po Pnn1 pe Name Signature <br />Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantily ❑Type ❑Residue <br />❑Pertial Rejection <br />❑Full Rejection <br />Manifest Reference Number <br />180. Allemate Facility for Generator) <br />U.S. EPA ID Number <br />7 <br />v <br />LL <br />FadliP/s Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Manor Oay Year <br />Q <br />Z <br />H <br />19. Hazardous Waste Report Method Codes (ie., codes for hazardous waste treatment, disposal, and recycling systems) <br />'Management <br />2. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous nationals covered by the manifest except as need in Item IBe <br />„ ` r Signature <br />Printed/Typed NaK.",'), <br />�9n 6 Ob <br />EPA FOnn6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF=REDUFRE8�- <br />10322.2017 <br />