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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST J J K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) .San .Nose S. Stockton, CA 9520:4.. Generator's Phone: :} )�S" 1 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number }r;0 175 4.22 8.Designated Facility Name and Site Address U.S.EPA ID Number iuz=a i,ay.jLroaffte`aLai bervaces, Inc. t'a.,t 13th Street Yuma Arizona 8,636 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. of NUN -RCCA RIAZARDOUS °IvAS'1'E SOLIDS 30 (OILY SOLIDS) Z 2. w O t 3. 4. a 3 14.Special Handling Instructions and Additional Information CAckI rw 15. GENERATOR'S/OFFEROR'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, 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 I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 16.International Shipments Ex ort from U.S. Port of entry/exit: /exit: Z 1:1 Import to U.S. ❑ p ry - Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials F- Transporter 1 Printed/Typed Name Signature Month Day Year O CL rn Z Transporter 2 Printed/Typed Name Signature e- Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity 1:1 Type Residue e ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U LL Facility's Phone: W - 11 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.