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DTSC. 04,11.8. 0817 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Apprgved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gened rr 56358631 2.Pagel of 3.EMTN 4M am Tracking Number <br /> WASTE MANIFEST 016772923 JJ K <br /> 5.Generzbr ,El1q"WK`WC- DDI-001 Generators Site Address(if different than mailing address) <br /> 3820 RHONDA COURT <br /> TRACY CA 95304 <br /> 510 719-3557 <br /> Generators Phone: <br /> 6.Transpodec6 `i'�MONMENTALSERVICES U.S.E6IA`Vr0e2 8 2 7 7 0 <br /> 7.Transporrtterr 2 Company Name U.S.EPA ID Number <br /> 8.Designalg Ead6LNarAVod,SitefA6R'fNC U.S.EPA ID Number <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: (323)277-1500 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NO <br /> 3 D IV <br /> � P <br /> w OC <br /> z 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 *PROFILE#9131:02/22/2017-02 OILY SOLID, PAPER FILTERS <br /> P500-00025813 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT vl// �/6 <br /> A7 7 v D?-3,5,-o?3 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATfON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for 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 EPAAcknowledgment 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)(if I am a small quantity generator)is We. <br /> GeneratorslOfferorsP' d(lypedName Signature Month Day Year <br /> 1 6 .Z <br /> —J 16.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Portntrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo Printedffyped Name Signature Month? Day Year <br /> a <br /> rn <br /> QTransporter 2 Printed/Typed Namegnature Month Day Year <br /> ax <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp j 1 <br /> ❑Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ;� Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. / � 2. <br /> 20.Designated Facilliity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> r <br /> ped Name /F_ _ �j/�'-I-•^' ,� Signature Month Day ar <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILIT TO DESTINATION STATE"µ;-tIf REQUIRED) <br /> 12545.0275 <br />