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Please print or type.(Form designed for use on elite(12-pitch)I.,, fler.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000414NA 209-389-2761 1 014373655 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d dlferent than mailing address) <br /> Central Valley Nems Sentinel 125 N.Church Meet <br /> P.D.Box 1380 Will,CA 95240 <br /> Lodi,CA 95241-1360 <br /> Generator's Phone: 2139-388-3781 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> California Environmental&Litho CAR000009910 <br /> 7.Transporter 2 Company Name U S EPA ID Number <br /> Rust and Sons CAR000197922 <br /> 8.Designated Facility Name and Site AddressC, <br /> t , L`,j �y/ U.S.EPA ID Number <br /> r-mauml/ ��' 19c; CAD097030993 <br /> 5375 S.BoylaAvenuo <br /> Los Angeles,CA 90058 <br /> Facility's Phone: 323-277-1500 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1 Non RCRA Hazardous Waste,solid(Waste ink conlamirated debris) CF P 352 <br /> 0 001 ��L None -- <br /> z 2. <br /> w i <br /> 3. <br /> 0C1912016 � -- <br /> ENV RON ENT L H r LTH <br /> 14.Special Handling Instructions and Additional Information <br /> 1.Waste plastic buckets,debris with ink # ERG#i 71 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acarately described above by the proper shipping�� are classified, ' <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 shipment and!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 /> 1. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ff I am a small quantity generator)is true. <br /> Sign�tura Month Day Year <br /> Generator s/Offeror's Printed/Typed Name I 1 <br /> ' `moi •.,(" 1�. ,' _.` V,,, +•, � � '�-i�ln-' <br /> 16.International Shipments Import to U.S. Ll Export from U.S. Port of entry/exit: <br /> F- ❑ <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt o terials MOIItli <br /> If ��edName Signature Y� <br /> a- Transp Day <br /> CL a��C ��" Morrlh Day Year <br /> QTransporter 2 Printed(iyped Name Signature <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> U.S.EPA ID Number <br /> r 181b.Alternate Facility(or Generator) <br /> E- <br /> J <br /> U <br /> LL Facility's Phone�Mteate <br /> Month Day Year <br /> Wt 8c.Signature F�a (orenerator) <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' 2. <br /> 3. F- <br /> 20. <br /> Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> Printed/Typed Name Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />