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` ''Pease print or type.(Foo►designed for use on erste 12 itch ORDER Fo m�� .OMB No.2050-0039 <br /> ( -Qt )typewriter.) <br /> UNIFORM HAZARDOUS i.Generator ID Number2 Pam 1 of 3.Emergency Response Phone 14.Mandest Tracking Number <br /> WASTE MANIFEST C A D 9 8 1 1 6 3 9 7 5 2 800_333-30.53 1004865327 JJ <br /> 5.Generetoes Name and Mailing Address Genarator's Site Address(d dfiarard than mailing address) <br /> STOCKTON USD STOCKTON USD—TRANS YARD <br /> 1944 N. EL PINAL DRIVE 1932 N. EL PINAL DRIVE <br /> STOCKTON, CA 95205 STOCKTON, CA 95205 <br /> Generator's Phone: <br /> 6.Transporter 1 Canparry Name U.S.EPA ID Number <br /> UNIVAR USA INC. IC A D -0 1 0 9 2 5 5 7 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> MXI MAUMEE EXPRESS INC IN J D 9 8 6 6 0 7 3 8 0 <br /> 8.Designated Facility Naim and Site Address U.S.EPA ID Number <br /> SIEMENS WATER TECENOLOGIES CORP. <br /> 5375 SOUTH BOYLE AVE <br /> VERNON, CA 90058 CAD 097030993 <br /> Facility's Phone: 323-277-1500 <br /> ga, 9b.U.S.DOT Description Qncludirg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pacidrg Group(dam)) No. Type Quantity WtNoi. <br /> 1RQ, HAZARDOUS WASTE SOLID, 1111.0.81 <br /> a (LEAD PAINT CHIPS), D008 <br /> X 9, NA3077, PG 111, (RQ-10), (ERG#171) 181 <br /> z 2NON RCRA HAZARDOUS NASTS,SOLID <br /> LU (OILY SOLIDS) D M <br /> 52 <br /> 3. <br /> 4. <br /> 14.Sial Hancibmtrudions and Additional Information <br /> 1. 350 <br /> I 07-22 2 ?-27 <br /> PLACARDS PROVIDED BY SIPPER DRIVER SIGNATURE <br /> **** ER CALLER MUST E'Y UNIVAR A AS REGISTRANT **** <br /> ***** PROJECT NUMBER: P026509 JOB START DATE: 03-23-09 ** <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fifty and accurately described above by the propor ftpmg name,and are ossified,packaged, <br /> marked and labeleftlacarded,and are in ad respects lin proper condition for transport adding to applicable khtema8aml and nationai go 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 26227(a)(d I am a kalle quantity generator)or(b)(iI am a small W is true. <br /> GeneraWstOtferoes Printed/Typed Name Signature Month Day Year <br /> -a 6.Intemational Shipments a Impot to U.S. it'" Port <br /> Z Transputer signature(for exports only ❑Export from U.S. r�# Date leaving <br /> ng emt• <br /> w 17.TransporterAcknowWliment of Receipt of Materials <br /> 1 Printte� Name C _. Month Year <br /> d -.-I.'.-,,- LZ F—g II )AN <br /> rn re r 2 'ted/Typed Name Sig Moo Day Year <br /> n Ila to 7 <br /> I&Discrepancy <br /> 18a.Discrepancy Indication Space Qrarntity Type ❑ReaMue ElPar lal Rejection ❑Full Rejection <br /> Marafast Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> W Facility's Phone. <br /> ilk.Signature of Alternate Facility or Generator) Month Day Year <br /> r <br /> y19.Hazardous Wage Report Management Method Codes Q.e.,codes for hazardous waste and recycling systems) <br /> ® 1. 2. 3. 4. <br /> 120.Designated Fa&y <br /> r perator.Cartficatiar of s covered by the mantled except as noted I m 1 <br /> yped NameSignature <br /> ' <br /> . � 1 <br /> EPA Form 8700-22(Rev.3-0S) Previous editions are obsole . DESIGNATED FACILITY TO DESTINATION STATE(IF RE01114D) <br /> 10529.0057 <br />