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2- <br /> Please <br /> 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 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST *z' A 'L 0 -0 0 0 4 L 6 �., �n � ��;r <br /> r trot u0 f's ELE <br /> 5.Generator's Name and Mailing Address Generator's Ste Address(if different than mailing address) <br /> ()taik stop tHawr.et`�,, ;Fnc . QuaM v*� a�rteatm,, i-n . #15", <br /> `C' 1 Ent- ;w7 �? wt Y��I 1?�1 S Cgero'i~e Ln- <br /> Lodi. CA g5��� <br /> Generators Phone: (5.i0 1445-22"K <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <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 /> 2000 N. Alaineds St., <br /> camt7 an ' CAL 9(]22-2 <br /> Facilltys Phone: ;10 e,.07 7 1 <br /> ga 9b.U.S.DOT Descdpfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WLNoI. <br /> IX 1. UNIM-:1, 'G2wo1inet !7G TI <br /> ti <br /> z 2. <br /> ILL! <br /> I HIS WASTE STREAM HAS BEEN QUALIFIED <br /> 3. <br /> DeMENNO/KERDOON FACILITY IN COMPTON, ---`--- --- <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY <br /> 4. VE YOUR WASTE STREAM AS <br /> QUALIFIED. OUR EPA NUMBER IS CAT080013352 -- -- -_-__ <br /> 14.Special Handling Instructions and Additional Information 3 <br /> nVL #:: .I2G "�,`R t b PR'IT C`!I`3E <br /> G;z"'-4,:.e & WAtt-r t tltt QuIK3` OR CCH. 6592a7 <br /> X' 55 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I 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)or(b)(d I am a small quantity generator)is true. <br /> Genera}lor'sl0flerorts PrinlecirTyped Name tilgnat ret i -,.., Month <br /> .A y Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export If U.S. Port of enlrylexiC <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> , <br /> Signature Month ay earTransporter-IPnledfT ped Name <br /> QTransporter 2 PrintedfTyped Name Signature Month Day Year <br /> F- a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ElFull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Q 3 <br /> LL- Facility's Phone: <br /> W18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> HZ <br /> e9 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> kkDesignated Facility Owner or Operator:Certification of eceipt of hazardous materials covered by the manifest except as noted in Item 16a. <br /> Pd ted/Typed-Nam/e ee I Signature Month Da r <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />