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L <br /> Please print or type.(Form designed for use on elite(12-pitch}typewriter.) Form Approved,OM8 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 0 J Ij 4 ,, _i -% b 5 JJ K <br /> 5 Generator's Name and WaifngAddress k0ai az dress(if different Than mail no acdress) <br /> ��,c� �, 4Al��r 239 S. STOCKTON <br /> GenerA0111 oe: f, - .�-� _ ,uy CA 95366 IPON CA 95366 <br /> 6.Transporter 1 Company Name J.S EPA 10 Numter <br /> 7.Tran_ yName U.IE IDL um er <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CLEARWATER ENVIRONMENTAL <br /> 2430 ALMOND DRIVE <br /> FaollhyNWER SPRINGS NV 89429 <br /> ga. 9b.U.S.DOTDe_rp IUnci in raper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13.NJaste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.IVOI. <br /> i. <br /> o 223--- I- --- � ----- <br /> NON RCRA HAZARDOUS WASTE LIQUID(OIL&WATER) <br /> 0011 TT— <br /> z 2. E <br /> w ! <br /> 0 - �----- E_ ---- <br /> t t <br /> 3- f <br /> E <br /> 4. <br /> I <br /> I <br /> i <br /> 14 Special Handling Instructions and Additional Infori lion <br /> WEAR PPE, ERG#171 <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 dassified,packaged, <br /> marked and labeledip(acarded,and are in all respects in proper condition to,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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a smaIt quantity generator)is Irue. <br /> Generalor's'Offemr's PrinledlTyped Name Sti�Wore Month Day Year <br /> '`'1�JJ fAPR0l Y " •r--, if rr v- <br /> J 16 International Shipments <br /> ❑Import to U S. Export lrom N,S Port of entrylexit <br /> Z Transporter signature(for exports only). Date leaving U.S.. <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Tr(ransporter 1 PrintedfTypeed—N-ammee Signatr Month Day Year <br /> QTransporter 2 Prinle Typed Name SignatuP Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quanlity Ll Type ❑Residue ❑Partial Rejection ❑'01 Rejeclion <br /> Manifest Reference Number <br /> } 18b.Alternate Facility(or Generator) U S EPA ID Number <br /> H <br /> J <br /> U <br /> LL Facili+y's Phone. <br /> W 18c Signature o(Alternate Fac.lily(or Generator) Month Day Year <br /> a <br /> a <br /> in <br /> 19.Hazardous Waste Report Managemea;Method Codes(i.e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> o f 2 3 t <br /> 3 <br /> 20 Deslgnaled Facility Diviner or Operator Certification of receipt of hazardous materials covered by the manifest eccep:as noted in Item 1 <br /> PrinledlTyped Name Signature Month Day Year <br /> rles L iol <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. I t St(il'd1l i 1.b I"�i.C'l�.I :'TCU IJS:.`;I'1i.11,l lf'1PJ c:i 0C RF.01111i <br />