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RECE1,2 D <br /> Please print or type, ,-1 Farm Approved,OMB No.2C-50.O039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Maaifes T Id N/u�m <br /> WASTE MANIFEST~ �ggM90002 1 925-423-42M O , Z�531 J J K <br /> 5 Generator's tl Name Mailing Address_ dress - Generator's Site Address(if different Men mailing address) <br /> IrEnl0ft %L%300 on b*W of`i!S 14NSA L13W X*UWftVWft NVI1DrW Lab Ste 300 on bdW 0f SFr NNSA <br /> P 040aa18O8/t-786 Ltimmi im G154551 CorM Hallow Road,Tracy CA%M <br /> Generators Phone: 925'4U-VM ATM Siligpft <br /> 6 Transporter 1 Company Name U.S EPA ID Number <br /> Cesar:Harbors EnvlrarwmrltA Servkes Inc. MA=9327ZW <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> B Designated Facility Name and Site Address U.S.EPA ID Number <br /> Penn Hari M ftftft%iDoW,U C 25M Went UDl0e1Tl R*4 kiftmwMam CA 93206 CAD9806M76 <br /> Facility's Phone. 661-M-6= <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11 Total 12.Urdl 13.Waslr Code. <br /> HM and Packing Group(d any)} <br /> No. Type Quantity WIN01. <br /> Ix ' NA2212,Asbestos,9,Ili JERG 2711 DOPM20B-1 I CM 40 Y <br /> 0 <br /> L <br /> c� <br /> 3. <br /> 4. <br /> 14,Spewl Handling Instructions and Additional Information <br /> Emergertt v Wspowe Phwe 925-473-4205 Conrad name 1J X Erner6emy D4aWL Load 0 Ri'bV2MIZ Scrip Doc No.-ro-249M <br /> RdWeMe Ir eMJllrMber LXFJD367 On kllvaki .5JVAPCD 4800 ErtrWlprlse Way,Modesto,CK 9S356 <br /> QflEI3E11023 MW -Ili jr,4"-r- -4 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby dedare that the contents of this consgnment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in atl respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am On Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste min;mization statement Identified in 40 CFR 262.27(a)(111 am a large quantily generator)or(b)(ifI am a smaj quantity gAerator)is true. <br /> GeneratoesfOfferoes PrinledlTyped Name Signature Month Day Year <br /> Scat A.Graham on betoff of t1-re NMA _ 2-4 l9 <br /> 16.International Shipments <br /> ❑Import to U S. ❑Export from U.S. Port of entryfexit <br /> Transporter signature{for exports only): Date leaving U.S <br /> 17,TranspoMetAcknowledgmeni of Receipt of Materials <br /> LU <br /> Transporter 1 yriniedrT Name Signature u ttt, Day Yaar <br /> ( - c��1�IY[_ J 1 <br /> z rler 2 Prin ediTyped Name -Signature l Month Day Year <br /> 1B.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 16b,Alternate Facility(or Generator) U S.EPA D Number <br /> u <br /> ua- Facilitys Phone: <br /> W 18c.Signature Df Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste P&pcft Management Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systems, <br /> �l j�,! 2. 3. T <br /> 20.Df ersigaatedX0j'Owner er Operator;Certification of receip�d hazardous materials covered by the manifest except as nded in Item 1 Ba <br /> Printed 1�arnel c �, Sri,natu 7 Drys Year <br /> EPA Form 8700-22(Rev.12.17) Previous ddiRions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />