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G4. 00. 21 1- <br />r ' <br />Please print or type. (Porto designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Furrn 8700-22 (Rev. 3-05) Previ rOdilions are obsolete. DESIGNATED FACILIT"tjO DESTINATION STATE (IF REQUIRED) <br />10322.2008 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFESTCAI <br />1 003884937 JJ K <br />71 <br />11 <br />S. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Central Valley Waste Service <br />133 East Turner Road <br />Lodi, CA 95240 <br />Generators Phone.4x <br />6. Transporter 1 Company ami U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Chemical Waste Management <br />CAT0�646117 <br />35251 Old Skyllne Road <br />Kettl2man City, CA. 93239 <br />Faalh ?s Phone: 559-3-971 T <br />9, <br />9b. U.S. DOT Description (including Pmper Shipping Name, Hazard Gass, ID Number, <br />10. Cc inehe <br />It. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Ouardly <br />Wtivol. <br />1. Noll-RCRA Hazardous Waste, Solid (5011 with lead) <br />i <br />OT <br />16 <br />Y <br />611 <br />ga <br />Z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additlonal Information <br />Wear Proper Claming When Hari Material. <br />ERG A NIA <br />Profile IF CA248562 soil eta leadl <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 dassified, packaged. <br />marked and Iabol"Placanded, and are in all respects in proper condition for transport according to applicable inewaeonal and national governmental regulations. If export shipment and 1 am Me Primary <br />Exportar, I certify Mal the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent. <br />hcertify that the more minimization statement identified in 40 CFR 262.27(a) (if I am a large gwnfity generator) or (b) (itI am a small quantity generator) is We. <br />Gegerators101 s PnntedfTyped Name 51tre Month Day Year <br />01�- <br />l///vl rA z g O <br />_u <br />16. International 5hipmerfts <br />❑ Import to U.S. ❑ Even from U.S. Port of enlrylexit <br />= <br />Transporter signature (for exports only: Date leaving U.S.: <br />w <br />17. TmnspoherAdnoviledgment of Receipt of MalenaLs <br />Transporter 1 Pnnmd4yped Name Signature / A Month Day Year <br />6 <br />M <br />Transporter 2 Pdntedflyped Name Signature Month Day Year <br />a <br />C <br />r <br />18. Discrepancy <br />I <br />18a. Discrepancy In ira6on Space El 1:1 Type ❑ Residue El Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />r <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />Q <br />I <br />w <br />FatllitYs Phone: <br />1aF.Sgnai of Altemam FaaliN(or Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1 /0 Cl 2 7. <br />4. <br />20. Designated Fadtiry Omer or Operator Certifiption of receipt of hazardous materials covered by the manifest except as Wed in Item 1W 1 <br />1 <br />PnntedlTyped Name " Signaurm Monte Day Year <br />D <br />EPA Furrn 8700-22 (Rev. 3-05) Previ rOdilions are obsolete. DESIGNATED FACILIT"tjO DESTINATION STATE (IF REQUIRED) <br />10322.2008 <br />