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Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.MaAI'fe55..t Tr�ki Nye erg, <br /> UNIFORM HAZARDOUS fi y eg �i s •i`�7't <br /> WASTE MANIFEST p.F1r1 9!'i'7FiiJ!a 1 R 'E5!"r:l.� S 6N 4' O1.,7 a,A 1 3" FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Weibel Winery <br /> 1 llttinerriestet Way <br /> Lodi, CA X52413 <br /> Generator's Phone: W5-945' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Admicsd Chcamical Trranspc4t hic./JORA AGI NVIRO GAIROOM70540 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> AdtA=ed Chern3 'TreettnsATt <br /> 8133 Edith Blvd NE Miwo.72OrS82. <br /> Albuquatique6, W 8710-1 <br /> Facility's Phone: 505�M9,4 Z?0 <br /> 9b.U.S.DOT Descri hon(including Proper Shipping Name,Hazard Class,l0 Number, 10.Containers r <br /> 9a. P r 9 PP 9 Quantity <br /> 12.Unit 13.Waste Codes <br /> HM and Packing Group(Bony)) No. Type Quantity Wt./Vol. <br /> 1 NON RCRRA HA7ART)OUS WASTE,LIQUID(011) � CBtut ^ P 221 <br /> Z Z. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Project Number 189999 G'- curnei5't A02.Z81D3 <br /> 1) ACT33410 ITA.- ! <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: 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)(ifI am a small quantity generator)is true. <br /> GeneratoeslOReror's Printed/Typed Name Signature .,t Month Day YQ�j <br /> 16.International Shipments ❑ �s°" <br /> f„ import U.S. Expel from U.S. Port of enfrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> a 17.Transporter Acknowledgment of Receipt of Materials <br /> To, <br /> ! sporter,1.Prnt9/d(Typed!Name SigatuVt , MonthDay� Y <br /> c! 71 41 t (° �r <br /> Qz <br /> Transporter 2 PririnftedfTyped Name Signature .A' Month Day Year <br /> K <br /> r <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 /> U <br /> W Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />