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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM NAIAMUS 11.Generator ID Number 2-Page 1 of 3.Errxrgency Response Phone 4.Manf dTraeId Number <br /> WASTE MANIFEST CAD981456023 2 800-�8263 0�0 3 6824 DAT <br /> S.Generators Name and Maili,gAddress ATTN:Mike Ubick Ganeratods Sae Address[if di ferent than meting address) <br /> Unirersity0fThe Padfic UniversityOfThe Pacific <br /> 3601 Padfic Ave 3601 Peclflc Akre <br /> Stockton,CA 95211 Stockton,CA 95211 <br /> Generators mane: 209-946-2908 <br /> 6.Transporter 1 Company Name U.S.EPA la Number <br /> Ingenium (Saaamento)(****ERI PHONE-Cult lD#8766-0004--) CAR000179747 <br /> 7.Transpoder2 Company Name U.S.EPA IU Number <br /> Ingenium (Miipifas}(****ERI PHONE-Gust ID#87fiB-0002****} CAR000179747 <br /> 8.Designated Faady Name and SbAddress U,S.EPAID Nunter <br /> Covanta ENmnmenfal Solutions LLC 1NR000127621 <br /> 6625 ad Porter Rd <br /> Pottage,IN 46368 <br /> Fad Phan: 260-240-2461 <br /> se, 9b.U.S.Dort r(including Proper ShipM Name.Kawd mess,ID Number, 10.Contsfr ers si.Tefal 1z Una 13.Waste Codes <br /> li nd P <br /> M aaddng Group(dany)) No. Type Quantity WUVoL <br /> Ix c 1Non-RCRA Hazardous Waste Liquid(waste ail) 223 <br /> �-O <br /> a 2 <br /> w <br /> L7 <br /> 3. <br /> 4 <br /> 14.special Raft g Instsucfiprig arldAMmal InWmationD 108399 SO 215558 <br /> 10 <br /> - 1}414 5 6 . <br /> antra retained bygenerator confers agencyauthotttyan initial transpotterto add orsubstltute addidonal transporters an generators behalf. <br /> 15. GENERATORVOFFEROR'S CERTIFICATION:I herebydedare that the contents of Sus consignment ere fully and accurately dwcnbW above by the pn4w0gsping name,and are dassifed,packaged, <br /> marked and tabsWoamuded,and are in ag respects in propercmMon for transportacaordng kr applicable adematiorreland national govarm wtal regulations.irexpprt shipment and I am the PriTay <br /> FVorter,I oortity that the contents of this oansignrrserst conform m the temis of the attacked EPAAdmavledgment of Consent. <br /> I certify that the waste Mh i nizatlon slat ment klarMed in 40 CFR 26227(a)(d I am a large quantity or(b)(d I am a smell quAtily generaloa)is tore. <br /> 2vPWs==ft Prinledlr Name Month Day Year <br /> El � � <br /> 16.Iraarrraticnel Shipments I�rt to U.S. <br /> ❑ExportfromU.S. Portofentryhmt: <br /> x Trensporter �(� °my)' Data leaving U.S.: <br /> W 17.Trampor uA*miedgmwd of Receipt of <br /> Tram"de 1PrintedfT Hearts Signa�stt Month Day Year <br /> a tf'K <br /> Transporter PdotedfrypedNama Signs Month Day Yew <br /> 18.Discrepancy r <br /> 18a.Discrepancy Inkefion Space ❑ quantity ❑Type ❑Residue ❑Pautial Rejection ❑FA R <br /> 113b.Altemata F Marrfest Rafererrca Number. <br /> (or Generatu) U.S.EPAID Number <br /> J_ <br /> C7 <br /> W Faplivs Phone: <br /> 0 18e.Signature ofMemete Faddy(or Generator) Morris Day Year <br /> Q <br /> a <br /> 19.I-Jazardeus Waste Report Management MOW Codes(i.e.,codes for hazardous waste treatment,d4osal,and recycling systems) <br /> I. 2 3. - 4. <br /> 20.Designated Facility Owner or Operator.Certification of remVof hm aldous materials covered by the mini d except as noted in Item 18a <br /> Pimtedrl'yped Name Sigrratu a Month Day Year <br /> EPA Form 870D 22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />