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i 1 ( J 1( <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form ADoroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Re1 <br />1'8468939) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number2. <br />f:Al-.Qititi0274f�Q i <br />Page 1 of <br />3. Emer en Response Phone <br />i eg&-468--1 760� <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />84 <br />(� -1 (1 FLE <br />5. Generators Name and Mailing Address <br />Generatoes Site Address (if different than mailing address) <br />Dha California Specialty Cheese <br />14253 S Airport Way <br />MANTECA CA 95336-8641 <br />Generators Phone: 209-858---96% <br />6. Transporter 1 pany ame <br />U.S. EPA ID Number <br />c FETY-•:1-EEN SYSTEMS INC <br />TXROit?100E!1 _AK, <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />CLEAN HARBORS ENVTRONMFNTAI RVr. TW., <br />MApA393�?��► <br />B. Designated Facility Name and Site Address CLEANHARBORS OF BUT TONW I L -L -OW <br />U.S. EPA ID Number <br />E. LOKERN ROAD <br />BUTTONWILLOW <br />, CA 9320f. <br />661-762-6nO <br />CAD98067527C <br />Facilit es Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID 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 any)) <br />Quantity <br />Wt.Nol. <br />NON RCRA HAZARNUS WASTE LIQUIDS <br />291 <br />o <br />, (LATEX GAINTS), W4)%,. <br />z <br />2. <br />i <br />LU <br />3 <br />4. <br />.__I <br />I <br />14. Special Handling Instructions and Additional Information TSD t Bl_ <br />DB@1190 <br />CSG t <br />4H EMFRGENiY800--- 4fa8-176rD—CH/SKiTFI—Contract <br />retained by generator <br />confers <br />agency authori <br />'T;-tT-i r. :»ter; --;r f- ' r c <br />- <br />f +� <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are <br />fully and accurately described above <br />by the proper shipping name, <br />and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable <br />international and national governmental <br />regulations. If export shipment <br />and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment <br />of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) <br />or (b) (if I am a small quantity generator) <br />is true. <br />GeneratoestOfferoes Pnnted1ypedName Signature <br />_.._ <br />Y Year <br />rc� LS ►h <br />16. International Shipments <br />❑ El Export from U.S. <br />Port of entrylexit. <br />H <br />Import to U S. <br />Transporter signature for exports only): <br />Date leaving U.S.: <br />IX <br />wledent of Receipt of Materials <br />17 Transporter Ackragrn <br />Montn ay ear <br />� <br />Transporter 1 Printed/Typed Name Signature <br />52 <br />nonth <br />z <br />ae Signature <br />Transporte 2 PnntedlT m <br />Y ear <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity []Type <br />❑ Residue <br />Manifest Reference Number <br />❑ Partial Rejection <br />❑ Full Rejection <br />18b Altemate Facility for Generator) <br />U.S. EPA ID Number <br />J_ <br />v <br />LL <br />Facilitys Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator)' <br />Month Day Year <br />Q <br />Z <br />19. Hazardous aste Report Management Method Codes (i.e , codes for hazardous waste treatment, disposal, <br />and recycling systems) <br />0 <br />1, T <br />. <br />3. <br />4. <br />JLC <br />20 Desgnat Owner or Operator. Certification receipt of hazardous materials covered by the manifest <br />except as noted in Item 18a <br />Printed/T me _ /� Signature <br />Month Day Year <br />t <br />— - <br />� <br />EPA Form 8700-22 (Re1 <br />1'8468939) <br />