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Please print or type.(Form designed for use on elite 12 lch)lypewdter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generamrto Numbw 2.Pagelof 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ChLUUr)31(P3% ! 4iU4.72't-121,V1 0040" 451,94 JJK <br /> 5.Generators Name and Mailing Address Generators SbAddress(If dialect than mailing address) <br /> SiAPPAIVAY, IFIL .AITAY#:707.644. N.I MC f y F. <br /> p 416 t2OSE:VVOOU ORIVe. SEtAr �'+ ' CI ?. <br /> AV <br /> PLi,At ANTON.CA x4;i6it 3"I'OCKTON,CA 9521)7 <br /> Generators Phone: 2044'72-mv <br /> &Tralspobart Company Name U.S.EPA ID Number <br /> k�NVIRf,)^IMF.Ni"hl..L00$110S.!NC 4'A1WQU1'i2.,i78 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> �s�N aqg� a U.S.EPA ID Number <br /> B.DesI '0)PF<N CI-IN ' 13iV1::t;S.INC. C,ADtIB24 41,!1? <br /> 1110 W.MOK1I'AVE <br /> Cla 953'16 <br /> Fecilys Phone: gut)421.7.012 <br /> gen 9b.U.S.DOT Description(incudmg Proper"ping Name,Hazard Class,ID Numbeg 10.CWIW ers 11.70ial 12.Unit I&Wasie Codes <br /> HM and Packhg Gmupp(amy)) Na. Type Ouatity WtNd. <br /> 1. ,ION ft(.RA ft)VAR000S VVASTE Sit.IQ .) ONi -p ':s,, , P *12 <br /> dp .. <br /> K <br /> iz. 2. HOW RCHA HAZARDOUS VVASTF I IO.(IR] � 19A6 ' _. G 194 <br /> 3. <br /> 4, <br /> 14.SpetlN HeadinglnsWc6rmsenMAddsmret Wameeat <br /> JOl)A88ORBl.NT U'u;"rll.i•ER:,YJO11 f±CiC:S 1 ' =. ': L41EAi@tiFaRiYPRIA'Tt?cc•I= <br /> Ongo_mov"ifthe:rnat0falolJ4=.��hinaen, e�tst,'m�..; <br /> d:Y <br /> befcyded as ew1tr CALK);or other <br /> 987.)WATNRLI i)27GI methgd wh1ch US['thetmaterla) .: <br /> ; <br /> TK`df•on th8land <br /> 15. GEW.RATOR'SIOMOR'SCERTIFICATION: IhombydedaethetmacanlentsoftNeconslgrvnentamutywdamumtetydesdbadabovebytwpmpershlppllgneme,erd.eredankled,pacsageq <br /> marked and Iabeledlplacarded,and are in at respects In proper cenddon rartransporteccadirg to applicable International and national governmental regulations.lf export shipment and I am the Primary <br /> ExpvW,I certify that the contents of this consignmeniconform to to terms of the allaGbod EFAAcknaMedgmentof ConsanL <br /> I cerg4y thatSie waste mnknoato,"2P erg ideniiled In 40 CFR 26127(a)(if l am a large quantity genaretor)E Ill amaanml quanOM generator)is we. <br /> Gercere ergrs PiFledRYped fYa�da Sigrebue Month Day Yea <br /> i f i <br /> iJ-• i6.Intatnallon SNpmints jr.'.`.."'LJ,�A,s1a U.S. ❑EV utfran U.S. P4 ofearryf It <br /> �, <br /> � Trenspanerslgneture(fa, Ports eery): DeOel gU <br /> cd 17.TranspodwAcknuMedgmentol Remltm aledals. <br /> � TrarePoderlPdr)teMYPad Hama Signetwe r:. Month Day Yea . <br /> Tmnsporler2Pdnfedlryped Nary)s Si ._ Monty DaY Year <br /> 18-Discrepancy <br /> 18e.Discrepancy hdcallon Space ❑ Ouentity, ❑Typa ❑Resldue ❑Padid Rejection ❑Full Ral-doe <br /> Manifest Reference Number <br /> 11W A1tem a Facility(or Generator) U.S,EPAID Number <br /> J_ <br /> V <br /> LL Facifdys Phone: <br /> aa 18a Signature ofAltsmate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Marlagaimat Meted Codes(I,a.,codas for hazardous waste treatment.disposal,and resyding systems) <br /> 1. 2. 3. 4. <br /> 20.Designaled Fadliy Owner w9parabor.Cerll6ca8on of mcelpt of hazardous materials covered by to manifest except as wed N Item l8e <br /> meype me r -;.1.. signature Month Day Yaw <br /> EPA Fare 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACiLITYTO GENERATOR <br />