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Please print or tvpe. (Form designed for use on elite (12-Ditchl tvnAwriter l <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Ma If at Trackln Number <br />WASTE MANIFEST C A L 0 0 0 3 4 5 9) 4 <br />11-3001424-93000 <br />(� 5 9 2507 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />CHEROKEE SWO AND REPAIR - OHE034 <br />900 S CHEROKEE LANs <br />LODI CA %240 <br />Generator's Phone: 201 "165-98,14 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ASBURY - - ,.,..(y ES C A D 9 2 8% 7.7 0 3 5 <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 />SIEMENS WATER TECHNOLOGIES CORP. <br />5376 SOUTH BOYLE AVPNIJ=. <br />LOS ANGEL E',' CA '9005ki C A U 0 9 7 0 3 0 Q 9 3 <br />Facilit 's Phone: I -V-.00 <br />ga, <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contalners <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />0 <br />362 <br />NDN-RCRA HAZAIiIJI01rL , WASTE, 30LID (OILY SOLIDS) <br />DM <br />-Zd <br />p <br />w <br />2. <br />UJ <br />C7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />NAERG#981 : 171 "PROFILE #98 . a)I09JI (ALYSOLIDS `PO#A110111301 "APPROPRIATE PERSONAL PROTECTIVE <br />EQul>'nNT <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 />markeq 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 I 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 />I I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator or (b) (if I am a sm ua)ty generalorLi5 true. <br />Generators/OfferorsPrinted(Typed Name Signat Moro Day Year <br />1� <br />� l� i U <br />� <br />F <br />16. International Shipments <br />1:1Import to U.S. El Export fro S Porto /1 -- Import <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W17. <br />Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed% ame Signature Month Day Year <br />O <br />IL <br />/ <br />/r/<Q G a <br />QTransporter <br />2 Printed(Typed Name Signa Month Day Year <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity Type 1:1Residue El Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed(Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />