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Please print Or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22(Rev.3.05) Mviouseditionsaieobsolete. - DE I#NATED FACILITY TO DESTINATION STATE (IF RECUIRED) <br />10322.2013 <br />I. Generator ID Number <br />UNIFORM HAZARDOUS <br />2. Page 1 of <br />3. Emeryency Response PDone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CAL=194d71 <br />I <br />1 <br />8Q0'321'10.� <br />003884930 JJ K <br />S, Generators Name and Mailin Address Generators SheAddress(if different than mailing addross) <br />Central Valley Waste Seri <br />133 East Turner Road <br />Lodi, CA 95240 <br />Generators Phone: 2043648274 <br />6. Transporter l Co pany Name U.S. EPA ID Number <br />Yel <br />T. Transporter 2 U.S. EPA ID ummoony Name ber <br />e. DeglePfllC�i Vdddl7P(leh U.S. EPA IO Number <br />35251 Old Skyline Road CAT000646117 <br />KeDleman City, CA 93239 <br />Fadli sPhone: 559-385-9711 <br />9a, <br />9b. U.S. GOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />17. Waste Codes <br />W. <br />Typo <br />HM <br />and Paddng Group (if any)) <br />Quantity <br />WtNol. <br />d. <br />I' NorFRCRA Hazardous Waste, Solid (soil vs" lead) <br />1 <br />OT <br />18 <br />Y <br />611 <br />0 <br />z <br />2. <br />w <br />f7 <br />3. <br />4. <br />14.S pecial Handling Instructions and Additional Information <br />Wear Proper Clothing When Handling Malehal. <br />ERG # N7A <br />Profile # CA298562 (1300 oA,ro lead) <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fray and accurately described above by the proper shipping name, and are detailed, packaged, <br />marked and labeled/placarded, and are in all respells in proper condition for transport according to applicable international and national gavemmental regulations. If ei shipment and I am the Primary <br />Exporter, I carry that the contents of this consignment conform to the temts of the attached EPAAcknewledgment of Consent. <br />I ceniy that the waste minimization statement identified in 40 CFR 261 (if I am a large quantity generator) a (b) (91 am a small quantiy generator) is We. <br />GeneratorsrOfferoes PrinletlRyped Name SgnaWre Month Day Year <br />b l <br />J <br />L- <br />16. International Shipments Export from U.S. Pon of en <br />El Import to U.S. ❑tryi <br />Transporter signature (for etports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Traporter 1 Print yped Name Signature Month Day Year <br />a <br />n <br />! 102 <br />Q <br />Transporter 2Pnnted/typed Name SigreNre Monty Day Year <br />K <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑RedPdNal Rejection on FWI Rel action <br />Manifest Reference Number <br />lab. Alternate Facty, (or Generator) U.S. EPA IO Number <br />J <br />U <br />LL <br />Faciliys Phone: <br />w <br />18c. Sgnature ofAltemale Facility for Generator) <br />Month Day Year <br />I -- <br />a <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (ie, codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />20. Designated Facility Owner or Operator Gertfiwreceipt of of reof hazardous materials covered by the manifest except as road in Item 13a <br />1 <br />Printednyped Na a <br />S g th Oa e r <br />EPA Form 8700-22(Rev.3.05) Mviouseditionsaieobsolete. - DE I#NATED FACILITY TO DESTINATION STATE (IF RECUIRED) <br />10322.2013 <br />