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1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST f' '.1,fJf�Q��( sf�) X10 t"7r_2`.00 1�!_� � .`.. J�-��� .I J J K <br /> 5.Generalor's Name and Matting Address Generator's Site Address(if different than mailing address) <br /> CFJ PROPERTIES <br /> 333 WEST C-r-]= STREET EZYING J TRAVEL PLASA <br /> NO_ SALT LAKE, UT 6405-1 1501 N. JACK TORE ROAD <br /> Generators Phone: 601 296-7700 Att"= RIPON CA 95366 <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> ADAMS SERVICES, INC- <br /> 7.Transporter 2 <br /> NC_7.Tran5porter2 Company Name U.S EPA ID Number <br /> 8.Designated Facility Name and SileAddress U.S.EPA ID Number <br /> DI'Z3EI'7NO/KEM)GION <br /> 2000 17 A,LM41EDA STPE-ET d' r <br /> COWTON, CA 90222 <br /> Fac6t sPhone: 31'! �3"-721?0 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> It 1.11011-11(Ta Hi ZARIIC[J3 WA9TE LIQUID <br /> p (CIL E WATER) <br /> a 1 Kp , <br /> W 2. IM NIM STREAM HAS BEEN QUALIFIED <br /> FOR AMOLING/TREATMENT AT THE <br /> 3. DeWNWI(ERDOOM Witif Y IN COMPMN, <br /> CALIFORNIA.THIS FACILITY HAS THE NECESS 0 T <br /> PERMITS TO RECEIVE YOUR VIIFSTE STREAMS I <br /> 4. QUALIFIED.OUR EPA NURWER IS CAT080013 52- <br /> 14.Special Handling Instructions and Additional Information VV=R, 1h i -L <br /> .'XC,Z?) £Z% b&41ii. EtU858is GLOVE2 <br /> CMITRACTOR: CHAFILEV E. THCM1-0 CO., I11C. <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,pa^kaped, <br /> marked and labeled/placarded,and are in all respects in proper condilbn for transport according to applicable inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cenity,that the contents of this consignment conform to the terms of B e attached EPA Admovdedgment cf Consent. <br /> I cemly that the waste minimization statement idenoled in 40 CFR 26Z.27(a)(il lam a large quantity generator)or(b)(if I am a small quantity gen,,alorI is true. <br /> GVenerelo slOfiero s PnntedrTyped Name I Signature Month Day Year <br /> V 1 <br /> -J 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Pod of enlrylexit: _ <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LM 17.Transporter Acknowledgment of Receipt of Materials l <br /> Transporter 1 P ntedfiyped Name Signature' / / f % Month Day Year <br /> of <br /> a ! 1_ 11 L 101J I\ It/I r 2 y p C <br /> QTransporter 2 Prinlecirryped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Typeff��I <br /> ❑Res due l-1 Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> F- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> LOU 18c.Signature of Allemate Facility(or Genaratof) Month Day Year <br /> Q <br /> Z <br /> S2 19 Hazardous Waste Repo"Management Method Codes(i.e.,codes for hazardous waste trealmenl,disposal,and recycling systems) <br /> U0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. rx'V"- DESIGNATED FACILITY TO GENERATOR <br />