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Please print or type.(Form designed for use on eY1e(12-pitch typewriter) Fom Approved OMB No_205OM39 <br /> 11,111111111M1. 1D Nttrt�er 2.Pagr 1 of 9.Enrgengr Pierce <br /> y� FW CAR00001 5560 1 8W �-MM ®134 2914 JJK <br /> O M' cPRESS CO INC 0 . RMM INC <br /> PO BOX 2569 1019 BESSEME.R DRIVE <br /> MANTEECA CA 95336 MANTECA CA 95336 <br /> wwwea Pieaee 209 823 - 2168 <br /> Name <br /> ENVIRONMENTAL SERVICES INC C A R 0 0 0 1 7 1 0 1 7 <br /> 7.Ttatrpeeter UA MIONLonhar <br /> 8.Des�natelyd$�/ rass U S.EPA ID Number <br /> #IVY 9511 MI S OF CY 16 ACRES <br /> BEATTY NV 89003 <br /> pact Phone. 775 553-2203 NV T 3 3 0 0 1 0 0 0 0 <br /> 9a. 9LU.&9WDww"mPdwftPMW9I1pF Meme,Flmd Clan,10 Neteribe6 10.t�rniaeeeie 11.Toll /2 Uetf q.M11nte Coda <br /> Hm mw f PrP Qwd Ne. T"M quardRy WWII <br /> t NCNB-RCRA HAZARDOUS WASH SLID(OILY DEBRIS, 223 <br /> p ABSORBENT) t bm Z 5,p P <br /> x 2. <br /> 3. <br /> 4. <br /> as ER 171 <br /> IA �1hi <br /> HAMLMR2 <br /> TO EE4UEER UM PPE.FR Canhir-tt#205M <br /> 15, GER MATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by gee proper shIpgng name,and are dasslfied,packaged, <br /> marked and iab"placarded,and are In al respects In proper oondi on for transport according to appkabts International and noWnsl governmental ragulallans.If export shipment ed I am the Primary <br /> Exporter,I certify that the contents of!tom consignment conform to dta terms of the attached EPAAckmvirledgmenl of Consent <br /> cerft that ft waste minimdallon statement identMed In 40 CFR 262.27(a)(If I em a large quantity gena or l a I quw ty generator)is tns. <br /> -0- IdedMilial Month Day Year <br /> a 2 <br /> 5.ntar Shipments Q import to U S. ❑Export from U S. Port of entrylaxtt <br /> Tw sporfer signature(for expods volt')' Date leaving U S.: <br /> IT.Titaeepaner 4ROoe�tdMebrkle <br /> TranepotMr t '00or <br /> moo Day Yaw <br /> ! Q loaf 2 <br /> 11TIaroporlar2FIdnileffilliped IWO lWaAbed Do Year <br /> I&Discrepancy <br /> I&Dlsaapancy indlatlon Speoe El Y t]Type ❑Reendtee ®Paltld on FW ReJxdon <br /> Nuneber. <br /> 11W A14tKnNa Pum(or tBeetsale U.S.gilt ID <br /> 141 FAM"PWW <br /> W ifc SlgnebttsaFAMneeleFetr(erCTerxrrabr) + ow War <br /> � 19. tlNaeteftePortl�epaeentllelrud0od�alls.,�odatorlwmrdsuexnoaMOwlawnt.�ael.aMnoyaBnPs�amd <br /> of 001,07 <br /> 20. FItdJApJrtOwworOpaefa:CoNatlata1mmlptafhmmdwarn'oi l com sdbyMrsrrtwilMnoWancNfnImm1fp <br /> 1 m7m, 1 rwWWAZI SIP141ure <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />