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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.ManifesIT cking Number <br /> WASTE MANIFEST "049293871 1 866-333-9222 <br /> � 100 901585 FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Corn probate International Inc 1021 Industrial Or <br /> P.O. Sm 6129 Stockton, Ca 95206 <br /> Stoc ton, Ca 95206 <br /> Generators Phone: 209 982-1920 <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number <br /> Advanced Chemica]. Tran rt CAM00070540 <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 /> Chlmsiaal Matte Nknagement <br /> 35251 Old Skyline Road <br /> Rattl4Wmn City, Ca 93239 <br /> Faculty's Phone: 558-386-9711 CAT000646117 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WlNo1. <br /> 0 1-Ill RCkA Rasardcos Mast, Solid (oily Solids) <br /> UJ� f p <br /> z z. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructionsand Addi6onallnformation <br /> 1) CASS 8497 c�R - p81-004 5 D� <br /> Rill t Nuill C"2915-01 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare 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.If export shipmentand I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)orb (if I am a small quantity generator 's true. <br /> G 0 rots-Pint /Type N me ig on a cur <br /> �s(a12 F lt ' DIy I� <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Expartfrom U.S. 41.1 of entry/exit: <br /> Transporter signature for exports onl : - Date leaving U.S.: <br /> W <br /> Tpffp gel17.Transporter Acknowledgment of Receipt of Materials <br /> � T p e 1 yped Name i r on cur <br /> Q Transporter2 Prtntetl(fyped Name Signature month Day Year <br /> C <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantfty ❑Type ❑Residue ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) - - U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> w Adl' s Phone: <br /> w 18c.SigpatureofAllemate Facility(or Generator) Month Day Year <br /> Q <br /> ED19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Desi FacilityOwnerrater Certification of receipt of hazardous materials covered by the manifest' s noted in Item 18a <br /> Pdntedr a Sign �o N e <br /> EPA Forth 8700 22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERA OR <br />