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Please punt or type.(Form designed for use on elite(i2 pitch)typewriter.) <br /> +xrrtppraved,ttlti 140.21)50-0038 <br /> 1.Generator lD,l(umbar 2.Pago 1 or ?.Emargancy Response Phone 4.N6`rniteso 6e 'l t <br /> 0N1F 3RD HAZARDOUS 80Q-G33-8253 1 O C] <br /> WASTE MANIFEST GALOg)040030 _ - ---- <br /> 5.Gehera€o�sNameandMailirlgkddressp'�"(N:Bill T8plaI Ceneratnfs-SitaAddress{8diflarenl-bran-mail'ue;addres8).m-- ----- <br /> G'€�of Tlrecy Waste,+velter Lel�ora#ory G'iiy of Tracy WastalxFtter Lsbl�ratary <br /> 391}0 Ni:A, Dr 3940 Holly Or <br /> TFacy.i,,A193041.618 Tracy,CA 953041818 <br /> Genehaw Phone: 209-8r31-4488 U.S.EP 0f Number <br /> 6.Transporter 1 Company Hama CAR000179747 <br /> ingenium ( scondldoxER!I PIONS-Gust IN 8766-0001} _ _ �-u.s.PA ID Number <br /> 7.Transporter 2 Company Name 1 (;AD9B2523433 <br /> Dillard EnlrbronmenislSOM-.8s ------- <br /> U.S.EPA ID N — <br /> F <br /> 8.Designated Facility Name and,Site Address <br /> f Clean Hafbom Are '"Re'LLC UTt]91�1SS2177 <br /> 11600 North tt Road <br /> 'E Grants ,le,U W29 <br /> Fara1 t}js Phone: <br /> 435-884$100 �` <br /> 10.Containers tt,'rotal 12.Unit 13.Waste Codes <br /> 9a 9b.U.S,DOT Da¢rdptioit(IncludiN Pn)per Shipping Name,hazard Class,fit Number, No Typo raurintfty W(Pot. <br /> HM and Packing Group If any)) <br /> x bN2920,Waste Corsosl18 liquids,flammable;n.o.s:{Sulfuric arid, <br /> 51 0 <br /> 3 -ILL P <br /> X Isopropanol),8(3),11 , <br /> z 2, — <br /> 3. <br /> t <br /> I _ <br /> i 4, <br /> 4 ' <br /> 14,SpeNHandiinglnstructionsand AddiUorallnfxmatpLh ment D47243 S8188 OId6f 65146 <br /> 1)ProiROGH 1=113795 DOT ERG#132 Fi <br /> 15. GENERAYUR'SrGFFEROR'S CE12TtFlCATION:thereby declaro tthalthe contents of this consign are Uly and accurately described above by the proper shipping name,atd are ciass'srieaaged, <br /> a,pa <br /> I regufatians.If export sl <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to Applicablelntematinnal and national govemmenlal dpment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment coolonn to the terms of the attached EPA AcknOlMedgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 202.27(a)(if I am a largo quantity{wnoralor)or(b)(if I am a small quantity gen ar)is f o. Month RV Year <br /> �ignalure <br /> Generate r'slOfferor`sPdName, <br /> t 16.Inlemaiional Sh' ants 1�t ❑Exportfrem U.S. f <br /> l J Import to U.S, Dale leaving U&. <br /> Transpohtor signature(for exports only): <br /> W <br /> 17.TransporlerAcknwAedgmantafRecelptcrMatedals 3 — —`� nn pay Year <br /> a Transporter 1 Ptinladfryped Name Signature Yr <br /> ar <br /> CL <br /> Transporter Printedlryped Nemo SrgnaWre �---- �"j <br /> 8.Di'Crepancy I ~ ❑Res duo rr]Padai Rejection � <br /> El Full 3eieaUon <br /> Space tiEl Type18a.Discrepancy Indication C} Qtenty <br /> I Manifest Reference Nuhrber. .U.S. <br /> USEPA ID Number <br /> ! � 18h.AllemateFaafity(arGanetala) <br /> f � <br /> If tdi. Facility's Phone: — Day Year <br /> l 180-.Signature ofAllernete Faalily(or Generator) �— <br /> ___ <br /> f � 19.Hazardous Waste Report Management Method Codas(i.e.,codes for hazasdaus wash treatment,diepasat,and recycling systems 4 <br /> LU <br /> 20.DHoqo,_ <br /> esignated Facility ovmer or operator Certification of receipt of hazardous materials covered by the manifest except as ratted in Item 18a _ Month D Year <br /> Signature /f f` <br /> l Printedllyped Name <br /> I FPA Form 8700-22(Rev.3 5) Previous,aditions are o6setefe. DESIGNATED FACILITY TO DESTINATION SPATE(IF FIEGUIRED) <br /> ) <br /> l <br />