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Pleasegrintoriypliia' ;•. J{ i. Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS T.Geneiator 10 Number r 2.Pagency Response Phone 4.Ma fest Tracking�Num or <br /> WASTE MANIFEST Ltd 1 of 3.Emerge785-, 12 i�9�7 2 5 FL E <br /> 5.Generator's Name and Mailing Address Generator's SileAddress(if different than mailing address) <br /> Cori-Flab California, LLC <br /> 1910 E. Lata an Road i <br /> Lathrop, CA 953W <br /> Generalors Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Advancers ChesrlioW Transport Inc./DBA AC IEWIRt <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and$Re Address U.S.EPA ID Number <br /> Chemical Wazte Ma rient <br /> i2-I Old tA�C 3°'1la <br /> Kettlan-fan GIty, CA 93239 i <br /> Facility's Phone: : 0-N71'f <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1D.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity wt./Vo. 13.Waste Codes <br /> af 1•Non-RCTZA Hazardous Waste Solid(Sdt CSA Y 352 <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information prrijact Nttrrlw 19531s McumeM#: D234423 <br /> 1) C:A615739 C" W 1 Irl•f ��� <br /> *- 15.,-GENERATOR'SIOFFEROR'S CERTIFICATION:'[hereby det larolha11he contents of this consignment are,fully and accurately destdbed-above by the proper shlppfigrrame;bird of t-classlfied;packaged;'' <br /> marked and labeled/placarded,and are in all respects in proper condlion for transport according to applicable inlemationaland national governmental regulations.If export shipment ands am the Primary <br /> Exporter,i certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)ol'(Ba(if l am a small qua Vty generator)Is true. I <br /> GeneraloesrODerces Printed/Tyjd N t Sgnatur �r /, Month fray}. Year !i <br /> 15 <br /> 16.Inlemational[Shipifients 77r-` <br /> ❑Import to U.S. El Expert from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> . i <br /> W 17.Transporter Acknowledgment of Receipt of MaterialsLLJ <br /> A <br /> Transporter 1 Pyr'l /Typed N Signature ! -. Month Day. Year <br /> IL <br /> N Transporter 2 Printed/Typed Name d Sgnatur Month Day Yee/ <br /> �1 <br /> 18,Discrepancy.:. <br /> 1B'DlwelpoM Indica8on Spam ❑ Quantity YP❑T e ❑Residue ❑Partial Re)ecllon ❑I d Rejedton <br /> .. . . r r., <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> uQ- Facility's Phone: <br /> 1110,Signature of Alternate Facility(or Generator) Month Day Year <br /> �I <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste lreahork disposal,and mgdklg systems) <br /> W —I—A <br /> ..,..,:. .. , <br /> ]2. 3. <br /> 20.Designated Fadlity Ovmer or Operator:Certification of receipt of hazardota malerlats wvered by the manifest except as noted in Ile-18a <br /> PrintedrTyped Name Slijnature Mop Day Year <br /> 05 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACIUTYZO GENERATOR <br />