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Rlease print or type. (Form designed for use on elite (12 -pitch) Noewriter.) ( " Form Annrnvari nun Nn 9nrn-nnzo
<br />orm - ( ev. 3-051 Previous editions are obsolete. ( DESIGNATED FACILITY TO GENERATOR
<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number
<br />2 P2'k' f
<br />•7
<br />3. Emergency Response From
<br />•rr•
<br />4. Manifest Tracking Number
<br />WASTE MANIFEST
<br />C A 6 5 i 2 8 9 0 5.
<br />`
<br />r -984-8178
<br />907735"7/22 3., JJ K
<br />Generators Name and Mailing Address Generators Site Address (if different than mailing address)
<br />Stockton Cyt{S
<br />8020 South Airport Way
<br />_ CA 95206-3999
<br />Generator'sPhoneLor f 2 P 3
<br />6. Transporter 1 Company Name U.S. EPA ID Number
<br />07 Q ,
<br />7. Transporter 2 Company Name U.. E ID Number
<br />8. Designated Facility Name and Si a Address U.S. EPA ID Number
<br />u- L._.
<br />Rho -Chem Corporat:•iolr-•fPSC') C r D 0 0 S 3 6 4 4 3 2
<br />425 ISIS AVE.
<br />0301-
<br />Facility's �tkrlij:IJ EWOOD CA 90301-
<br />9a
<br />9a
<br />9b. U.S. DOT Description (inclu ing Proper Shipping (fame, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />HM
<br />and Packing Group (if any))
<br />Quantity
<br />Wt.Nol.
<br />13. Waste Codes
<br />No.
<br />Type
<br />1.
<br />Rj-'. Waste Paint related material, 3, UN1263
<br />213
<br />PGIII
<br />II
<br />-
<br />DOO! D(,,c :rOC---
<br />z
<br />2.
<br />RQ Waste, Flammable, liquid, n. o. s . (diesel ,
<br />331
<br />p
<br />D003
<br />3.
<br />4�ast.e, Fla.1.1a -able Solids, organic, n.u,s.
<br />E,
<br />:343
<br />(mineralppir4 ts) , 4 .1, L`A1I325, II (paint
<br />P
<br />l
<br />7
<br />Do 01
<br />4.
<br />110 Hazardous waste, liquid, n. o. s . (Lead,
<br />222
<br />Cadmium) , 9, NA3082, PGII I
<br />I
<br />�
<br />��
<br />DOOF,DitOt,
<br />' 4. Special Handling Instructions and Additional Information
<br />1 rJS poi snt B'� I ar. ed f•13t a f: i X91,`_+ PRFO 300431-GEERCO 128
<br />2 '): C.`I.ES',�3 file] �R.F# 300431-OtFFit3# 12P DILL T0: a vAe{njr�
<br />t ?ii P21lnr _iebtls ^ar1:: fP-FR 306433-C:;ERG6 i3+ Work Ordzr: i44.18
<br />,� '1'3 31U -J f=' 1-N.F* 30045E C:FERGO 1")s Po"11 .3P �.�r1r1 11-I.-�){ti15 -ilfJ3 i
<br />15. GEN ERATOR'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 labeled/placarded, and are in all respects in proper cond)tloh 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 i�nform to a terms of the attached EPA Acknowledgment of Consent.
<br />I
<br />certify t the waste minimization statement jdenfified in 40 CF 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Gener+ol's/Offer Pn to Jyped_Ne Signatqa--- r . Mp�thf Day Year
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<br />Y� f Y
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<br />1 16. International Shjpments
<br />Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />-
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />w
<br />17. Transporter Acknowledgment of Receipt of Matedals
<br />�
<br />O
<br />Transporter 1 Printed7Typed Name i Signature _-._=
<br />, ., 9 i: , Monte Day, Year
<br />/ {
<br />N'
<br />�i J
<br />_ f
<br />-'•-`- `s. � � d� ,�G� f. � 1.,: �'�..--s- a -Y _.ice/%. �'�_. �-" /
<br />ZQ
<br />Transporter 2 Printed/Typed Name Signature Month Day Year
<br />F-
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ ouanfity ❑ Type ❑ Residue ❑Partial Rejection ❑Full Rejection
<br />Manifest Reference Number.
<br />181b. Alternate Facility (or Generator)
<br />J_
<br />U.S. EPA ID Number
<br />V
<br />LL
<br />Facility's Phone:
<br />LU
<br />18c. Signature of Alternate Facility (or Generator) Month Day Year
<br />Q
<br />Z
<br />C7
<br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1 ) If ,
<br />b
<br />2.
<br />-.( t�'_--1--1
<br />r
<br />4.J,
<br />1 � t
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br />P ' ted/T ped Na a _. signature
<br />-- \M th Da Year
<br />CS
<br />EPA
<br />F 8700 22 R
<br />orm - ( ev. 3-051 Previous editions are obsolete. ( DESIGNATED FACILITY TO GENERATOR
<br />
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