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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 14.Manifest Tracking Number <br /> WASTE MANIFEST CAS 191111€X1.9 9 POU-424.9300-Pr-Cf. 014821733 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> San Joaquin County Eirrironeri i HlsaN31 C)ept Hain. 1 ane 10D Yard.Eau;of Locual.T,ee R61855 EAST HaMon A.veraUe v " <br /> c4ndMon.CAS52C7+ Lrd, CA 962.140 <br /> Generators Phone: 208-453-Cr%1 7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> PARC Specialty Contracfora CAROOf!159k'46 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> PSC Ersiror%nnorwal SenncestAPrxnona-L.P CA0983649l <br /> 8.De**ZWVamfend Site Address U.S.EPA ID Number <br /> 425 Isis Averlsm CAD+H!8?�4443'2 <br /> Inglexvood. CA 40301, <br /> Fadliles Phone: 323.776-6733 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNo1. <br /> X 1. UI 2811.Toxic"ds,Orgwvc.N.O.S.,i0ebns,F"cide),6 1,PG 11 1 nF 15 P 357 <br /> 0 <br /> z 2. <br /> W <br /> (9 <br /> 3. <br /> 4. <br /> 14.Sppeeccial Handling Instructions and Add!tional Information <br /> ER/3Y 154-ERG book in c;ab-Wear approMates PPE when handling <br /> 1(1x'30) <br /> ERERd12017-05-03 - Jobil357024 <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 Iabeledlplacanded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify,that the waste minimization statement identtfad in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)KI am a small quandty generetor)is true. <br /> GeneretoesrOffrots PnnledRyped Nbme Signature _ � q. Mpdh D Year <br /> 16.International Shipments <br /> i1:1Import to U.S. ❑Export from U.S. Port of entrymitit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w .17.TmnsponerAcknoWedgmenl of Receipt of Materials - <br /> Transporter 1 Printed(0yped Name Signature.., Month Day Year <br /> a 7 ___, w� y / _ - r� 17 <br /> y _ <br /> Q Transporter2 Pnnted/ryped Name Signature n Monts Day Year <br /> K <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Tye Residue ❑Partal Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 181b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 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 Item 18a <br /> Pnntedr0yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />