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F11- "() - 47 1-1 �- (-I, rl-. <br />mmse <br />print or type. (rorm aeslgnea <br />for use on eute t iz-pncn) typewriter.) <br />- - <br />runii „ppiuveu. tnvro rvu. zuou-uuov <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />007735851 JJ K <br />UNIFORM HAZARDOUS <br />1 • Generator ID Number <br />WASTE MANIFEST <br />C 1� 6 5 ;1 ; �- J <br />15 F;) 18 Q--81, % r <br />• generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Stockt-ot: CS24S <br />8020 South Airport Way <br />r stogy}- V CA 91206-399. <br />h '7 - <br />Generators Phone: c. _ i Q ? <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />0, C; . V a t -t u.m [rt c. t' n n r z c <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 />Rho -Chem, LLC (PSC) CTa D 0 0 0 3 6 9 4 3 2 <br />425 ISIS AVE. <br />Facility's <br />ga <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 />Ir <br />; _.i <br />1.htort-Ft.R�1 <br />- <br />compound) <br />l� <br />p r- <br />i <br />z <br />2. <br />3. <br />4. <br />i <br />Special Handling Instructions and Additional Informa :on <br />f i.VACUUtd. <br />fnfr,rF (_t,^,ipr 4 .11OF? <br />i009-.0 12 <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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations.lf 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 identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is <br />Generator Offerors Pr nted(fyped Name Signature, i Month Day Year <br />H <br />16. International Shipments Export from U.S. / Port of ent lexit: <br />❑ Import to U.S. ❑ p ry <br />z <br />Transporter signature (for exports only): % Date leaving U.S.: <br />IX <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />_. <br />Cn <br />Za <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />r- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantityyp j j <br />T e ❑Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />C3 <br />18c. Signature of Alternate Facility (or Generator) <br />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 />2. <br />3. <br />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 />P�'ntt dJJ ped Name - _ Signature `'th Day Year <br />LA l at, ? chi � Z` �✓1.. - <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. ' r DESIGNATED FACILITY TO GENERATOR <br />