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nt or ,(Form de ' ed for use on elite 12 tom)- Form Ap ved.OMB No.205NO39 <br /> 3WFORMHMARDIDIJIS 1 <br /> 1.Cieneratur 10 Number 2 Page 1 aI 3. Reapohse Pune 4 Manifest Tracking Nummv <br /> WMANIFEST C A R 0{k 0 0 08 0 T 3 (800114 113RIF <br /> Y' 5. tDes Name and.MellingSite Address(if d t than mailing address) <br /> A. #e .1 .W.I'A `! <br /> P.O.am inwo ,, 120 FMNKW C <br /> SACRAM9MV CA 1 STOCKTON CA $5926 <br /> Gen s Pune: <br /> 8.Transporter 1 Company Name U.S.EPA ID Nu <br /> 7.Transporter 2 Company U.S.EPA ID Number <br /> B.Designated Facility Name and Site AddressU.S.EPA ID Number <br /> r` <br /> COWTON CA 9022 P <br /> Fadil(&Phone. 2 4;A T O 0013452 <br /> ga. Rb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,tD Number, 10.Containers <br /> 11.Told 12.UnkH14. and Padang Grou4)(if any)) No. TypeWiNV, 13.Waste Codes <br /> 1. <br /> 0 223 <br /> ® ti s <br /> Z. I <br /> 3. ` <br /> S <br /> P <br /> 4. <br /> f i - <br /> 94.Special H06ftinstri c1lons and Additional 1 on <br /> AlHOWTNECLARE"P"RW AMMOM EPA COW.-981-.NNE 3M-TE PER-KINA1, <br /> r1f7i El 2, 111, 11 f <br /> 15, GEN 'SIOFFEROR'S CERTIFICA :1 hereby declare that this contents q.fltis=wgnmWA are fully and a by the proper sh$ong name,ad. a r� ' <br /> marked and Ia eW rda1,and are in all rcr-�acts in for transportto applicablei ''and mrhtal reguladons.8 export shipment and t am the Primary <br /> Exporter,I that the is of this w cordorm to the terms of the attached EPA of,,,Consent <br /> I cerdk that the waste ft0kidzation statement iderdifled In 40 CFR 282.27(x)Of I am a targe quantity generator)or(b)(NI am a conalu <br /> q softy tor)is true, <br /> orwifaroes ft Signaturet <br /> e <br /> F 11B.InternalidnalShipments ❑Impo U.S. <br /> ❑F_xpott from U.S. 41k en"AI il:, Y <br /> Transpo-dar signature(for exports only): Date li:S.: <br /> 17.TransporlerAclutowledgment of Receipt of Materials <br /> 12 Tm-nspodw 1 Ptintedirryped Nam Signatu <br /> R . tai �t.y J 11 GI ✓r <br /> Mc <br /> ° aril <br /> T 2 Nam Sig Month Day year <br /> 1B.Discrepancy <br /> 1 Be.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Re)ection ❑Ful <br /> Refection <br /> Manifest Reference Numb <br /> 18b.Attemate Facility(a Getheratar) U.S.EPA ID Number <br /> t3 .. <br /> uu1- Fadlty's Phone: <br /> H18a Signature ofAltemate Featly(ot Gerherator) Month Day Year <br /> L <br /> 19.Hazardous V&Vte Report Management Method Codes(i.e.,cotes for-bizardcm waste treatment,d' 1,and recycling systems) <br /> 1. 2. 3: 4. <br /> 20.Designated Faulty Owner orOperator Certtatlon of receipt of hazardous materials covered by the maniliest except as nded in Item 18a <br /> Signature Agar err <br /> EPA Form 8700-22(Rev.3-05) Previous edifions are obsolete. TE$ANSPORTEfIi'S CONY <br />