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1_ <br /> lk <br /> Please print or type. Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator Ip Number 2, Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST : {�,t;UX1024F.;e8E3 E 94E1 :�?i �;fd7 ® 1101 . J �( <br /> � <br /> 0 <br /> 5. Generators Name and Malting Address GeneratorsSite Address (if different than mailing address) <br /> COUNTY OF RAN JOAQUIN PAI*Kt4 <br /> '11793 ESE 1AICKE t31i0VE RD. , <br /> LORI , CA �5240 <br /> Generators Phone:I;)Mcr%:;.7sy,,yj C <br /> U.S. EPA ID Number <br /> 6. Transporter 1 Company Name <br /> RP. K)jt ENtAE' ONNIENTAE_ SERVICES IN . L�t304dOt7� . <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> B. Designated Facility Name and Site Address U.S. EPA ID Number <br /> RAf;IOS ENVIRONMENTAL Sr'_R"ACES IiVC. <br /> 151 >>> St" UTO W!R RCS, " <br /> 1AIEST SACRAIJENTO , "CA 951:+91 <br /> Facility's Phone: 91 &371 ,5747 <br /> 9a. 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 Parkin Grou Jany)) No. Type Quantity Wt.Nol. <br /> 1 NON RCRA t- ,&MROEaUS VVAsT1 E 800b (C11L, DEBRIS) <br /> 114 ' <br /> z 2. <br /> LU <br /> 0 <br /> 3. <br /> 14. Special Handling Instructions and Additional information ' `F , <br /> 9Cd1 ) 1 �FEuFEE i ER ' <br /> [VkNDL.ERS 100 BE TRAINEES AND USE APPROVED PPE. <br /> P R. CONTRACTOR: RA3,40S ENVIRQAimI NTAL SERVICES <br /> 15: GENERATOR'SIOFFEROR'S CERTIFICATION: 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 igall 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 EPAAcknowiedgment of Consent. ' <br /> certify thatthe waste minimization statement identified in 40 CFR 262.27(a) (if.] am a large quantity generator) or (b) (if l am a small quantity generator) is We. <br /> Generalors/OHe es Printed/Typed Name Srg tura . Month Day Year <br /> � kx" � . JAI ,� - I 1 ('is <br /> 16. international Shipments Import to U.S. . ❑ Expoit from U.S. Port of an /exit <br /> F-- Date leaven U.S.:. <br /> ? Transporter signature (for exports only): 9 <br /> W 17. TransporterAcknowiedgmentofReceipt o( Materials <br /> W Signature Month Day Year <br /> Transporter 1 PdntedR,y/ped Name <br /> Z Transporter 2 Printedfryped Name Signature' Month Day ' Year <br /> i8. Discrepancy <br /> IBe. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Aitemate Facility (or Generator} U:S. EPA ID Number <br /> Jy A . <br /> rdi. Facility`s Phone: <br /> W 18c. Signature of Altemate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> 019, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 i 2. g 4. <br /> 20, Designated Facility Owner or Operator: Certification of re-AAAAAceipt of hazardous materials covered by the manifest except as noted in Item 18a% Month Day Year <br /> Printedfryped ame Signature � <br /> EPA Form 8700-22 (Re . 1217) Previous editions are obsolete. DESIGNATED FACILITY COPY <br /> IF YOU ' ECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT. SEE INSTRUCTIONS ON REVERSE SIDE. <br />