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Please print or typp.('Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No.2050.0039 <br /> T1.Generator IO Number 2.Page 1 of 3 Em <br /> �li(1 FORM HAZARDOUS a9 Emergency Response Phone d.Manifest Tracking Number <br /> WASTE MANIFEST G�i193i d5 1'J BOD-9675 1f o f)12 '-,' 6 8 I-313 J J K <br /> i.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> Caltrans 101-0 10(Stockton krrc ) <br /> t7?5 ES9t Cttarfef V><a) 1604,South 8 yI <br /> ;,cklon.Ck 9-5201 USS. 31100 ton,CA tiSik <br /> Generator's Phone: <br /> 5 Transporter 1 Company Name U.S.EPA ID Number <br /> DILLARD EIP,4RUht1.1EP1TuL SER-ACES C-=2523453 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.D" gnaCteyi•€a° Iart�e, d S'�r�3ddr�trssjl t U.S.EPA 10 Number <br /> rllcrrr�.av Si - 12 I.IILFs Sa11T-ti OF searr i Id+rT.3'1F7t�? <br /> LiEATT1',M! 66033 U31 <br /> Facility's Phone: 40•239.3943 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10,Containers <br /> HM and Packing Group(if any)) 11.Tota 12.Unit 13 Waste Codes <br /> No. Type Quanta tvt rdd <br /> X 1. RA3077. RAZARDGIaS WASTE �rLlD, hi G.s (LEAD Pa.II9T CHPS)9. �^) Did C c - ��C�� 181 <br /> o M <br /> J <br /> 2 Mort RCRA K32ARDOUS tV•6%.SiE SOLID(rjILY DEBRIS) <br /> c7 <br /> J}1 RCR15 R&Z.4.RDOLIS WASTE LIQL►1D (LhXEjC AND tt AMF:: ) <br /> Lf 'uV/2 6 4.'rf_ .-4- Z4IA I !lr'- �C1�✓1 . 37Fni,ctj <br /> 14.Special Handling Instructions and Additional Information <br /> DES.J08 0 3n210-064 <br /> 1 07012.630:1-1 S.Y 2 k SS 3,07011 31570-ECM <br /> 2 0701233048175 — I v S <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately desotbed 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 govemmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mirtimization statement identified in 40 CFR 262.27(a)(if I an a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOderors PrintedTyned Name Sig a re Month Day Year <br /> -r ill L(.r9 _ <br /> -r 16.Irtematioral Shipments <br /> ❑Import to U S ❑Export from U S PCrt of entry'exiC <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17LLJ .T rterAcknowledgment of Receipt of Matar�ist <br /> oTran po 11 r�r1nledJT ed Name / �* t r Signature J/ //�- �Cn p; /ar <br /> Ln <br /> Q Transporter 2 Prinladlryped Name Signature Month Day Year <br /> F- <br /> 13.Discrepancy <br /> 1 Ba Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA IO Number <br /> J <br /> :J <br /> ca+- Facility's Phone: <br /> M 13c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling ms) <br /> ' 11t- 2 N(3L 3 I�r��� ' IJ13 �- <br /> 20.Designated Facility Owner or Operator.Certificatiga of receipt of haza(tlous materials covered by the manifest exoe as riled bt Ilem 18p <br /> Printed?yped Na r1 -'` �A \�60 Signature� � Month Day �ea <br /> EPA Form 8700-22(Rev--Ms) Previous e#iorls are obsolete. ( DESIGNATED FACILITY TO GENERATOR <br />