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;ase print or type.(c=orm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS ' Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST CA CM71630 i 209-%3-1 N9 015864899 JJ K 5.Generator's Name and Mailin Address Generators Site Address(if different than mailing address) OLD CASTLE SIE RA BUILDING SUPPLIES 4202 GORALTER STOCKTON,CA 9520 Generalor's Phone: 209-21W-16G9 6.Transporter 1 Company Name U.S.EPA 10 Number George W. , 1-04q,Rio, C",Rt1O0047019 7.Transporter 2 Company Name U.S.EPA€D Number 6,DetF� r�9ddres5 U.S.EPA ID Number 17 E.i 3ttt St. - A "51 YUMA,AZ 85,,65 Facility's Pnone: � ga, 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,Noi. 13.Waste Codes X ' NON RDRft riA7-ARf7C7.tJs WASTE SC1LtR(otlp an56Tb2Rt &d1?bttx) DIA P 362 z. 3. A 14,Special Handling Instructions and Additlonai Information USEGL 1 US .� tJE GLCIVES INVOICE�F 8-q 41 k5 15, GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby deufare that the contents of this consignment are fully and accurately described above by the proper shipp€ng name,and are classified,packaged, marked and labeledlplacardod,and are in all rsspe0 s in proper condition for transport according to applicable International and national governmental reguialdns.If export shipment and 1 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 26227(a)(if I am a large quantity generator)or(p (If i am a small quantity generator)is true. GeneratorslOfferors Prince ed Name Signature Month Day ear !Gy �iEB I•�. � 15.International Shipme s ❑Import to U,S. ❑ _ p Export from U.S. Port of Transporter signature(for exports only): Date leaving U,$,: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name 7 Signature Month Day Year Transporter 2 PrintedlTyped Name Slgnatu Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typ e ❑Residue ❑ Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Altemate Facility(or Generator) VS.EPA ID Number Facill ys Phone: 18s.Signature ofAfternate Facility(or Generator) Month Day Year 19,Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) . 1. 2. 3. 4. 20.Deslgnatsd 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 Form 8700-22(Rev.3.05) Previous editions are obsolete.