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Please print or type.(Form designed for use on elite(12yilch)typewriter) Fort Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pagelol 3.Emergency Response Pham 0.Mandest-fraeldng Number <br /> WASTE MANIFEST ;. A ( f) Z s i '1:'.4-9a^CA C]'lilfl(fi'C .'�'�96 JJK <br /> 5.Generators Name and Making Address Generator's SileAddress Of ddfewdthar mailing address) <br /> i iXXA <br /> RTON RD <br /> 1 `N CA 95709 <br /> Gene <br /> 6.Transporter l compamy-NameU.S.FPA ID Number <br /> I ROVI IL!`d1y ENMONMENTAL SERVICES RIC; G A R 0 0 0 1 7 1 0 1 7 <br /> 7.Traepaler2 Qmpany Nance U.S.FPA ID Number <br /> X11 '-AFd 1A " "QSP; f ! -Il A f ( 1 f4 -1 f: <br /> 8.Designated Faddy Name and Site Address U.S EPAID Number <br /> CLEAN IrMBURS <br /> 1021 BERRYCSSA ROAD <br /> Sr'tN,.IC?,cif,:: CA 961.91 <br /> Fadtitys Pham: 1, -n CA 1) 0 k' A d A xt . <br /> ga. 9b.U.S.DOTOescripfiom('ealWing Proper Shipping Name,Hazard Class,ID Number, 10.CaNalnea 11.TOW 12 Una 13.Waste Codes <br /> HM and Pig yep Cie*) NO. Type Quantity wuvbl. <br /> o phC1N Rt;idA NA7Rk�DOlf6 WASTE?.LR3Lfi[ ,((:H.,SEP1At'': <br /> 21 <br /> r f,-VA IER) <br /> W <br /> t, <br /> 3. <br /> 4. <br /> 14.Special Handling lnstiuctiansand AddNonal Information 1µ'>N+EM;3914AL1SEFTAGF WATER tRCV111 <br /> 6k 1✓ 5 <br /> f ji.E'�:i�G 3.,7Pi 'tf.{ifF`frw.E ':vl�":Trt 7lNL+1l�,fc'#.r,L, 61Rtl1'MVrt14;ANQ UN!YPT!. <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION:I hereby declare that the contents of this consgnmentare fully and accurately described above by the propershlpping came,and are classified,packaged, <br /> marked and labeled[placarded,and am In all respects in pmpercondition fa to sport according to applicable intemationaland national goremmenlal regulations,If export shipment and l am the Primary <br /> 6poder,I certiythat the contents of this consignment conform to the tams of the attached EPAAcknoWedgment of Consent. <br /> I ceNfy gat the waste rdnimintion statement identified in40 CFR 262.27(a)(81 am a large quanfily generator)or(b)(til am a small quantity generator)ishue. <br /> Generator's/Offerors PrmWyped Name Signatum Month Day Year <br /> w . <br /> -J 16.International Shipments <br /> r ❑Importm U.S. ❑Exponhom U.S. Pod of enby/exit <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> w 17.TansportaAtlm/owieedddgment of Receipt of Materials <br /> Tran Berl Pnnedfl' Name Sinatme Monte Day Year <br /> a <br /> 2 Transporter 2 Printed?yped Name Signature Month Day Year <br /> C <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑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 /> tea. Facilitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardau waste treatment,disposal,and recycling systems) . <br /> 0 1. 2. 3. 4. <br /> 20.Designated FadlityDwner or Operator.Certification of receipt of hazardous materials covered by the man'dect except as noted in Item 18x <br /> Pdntedffyped Name Signature Month Day Year <br /> EPAForm 8700-22(Rev.3-05) Previous editions am obsolete. GENERATOR'S INITIAL COPY <br />