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I Please7print or type. (Form designed for use on elite (12 -pitch) typewriter.) IlliForm Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05)- Previous editions are obsolete. J DESIGNVD ACILITY TO DESTINATION STATE (IF R& WIRED, A 7 i7i O� - 1 4 7f 7 L2t,,3 CAL"0917,R2732 c!4P;_A533;R8 0 L!� L UNIFORM HAZARDOUS 1 Generator ID Number 2. Page I of 3. Emergency Response Phone 4. Manifest Tracking Number CAL00038 WASTE MANIFEST 376-6 1 0 08680360 FLE 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) 0,3 It I ;-k r-- G e n e r- a I #143_53 1) # ' 43 5 3 2-092 7 5 1 5 E 0 1 -1 E A V'E E Q S I- M I T E A V E " f - Generators Phone: MANTECA, CA 95336-5923 A, A J 8 6. Transporter I Company Name U.S. EPA ID Number ST,I 'S P e t W a R t 2 t,- I lj t J* It— 7, Titer 2 CompNany a� Jr7 I _ Z> 8. Designated Facility Nate and 83tf/Pfildrens 2I5t Century EMN, LLC U.S. EPA 10 Number 2095 Newlanda Dt-� Fact F er-n I e y NV 89408 ' 0 Facili)F's Phone: 1 7';'_ 527 N D9& 3 9a, 91b. U,S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13 Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. X I)i N 1 :) Z) V!, Ws s t. e V4 c r o s ra 1. s [_�Mmable c.1, ERG#126 I C F L71 Q1 0 14 P 3351 D121101 ir O X 21IN17,91. W-Am-'te Hypochigrite Scl#itions 8. PG; I C' F of 0 CA IC -4 P, i2;2, LU III, ERQG#1554 3. 4. 14. Special Handling Instructions and Additional Information 1 1 1054 1 A e r a s o 7 15- GENERATOR'31OFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent - 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 genera loT'Nse. For Son ay Year 'wz 1A V 11 1 16 X011;: Imam al Shipments o, mport to U.S. ❑ Export from J.S. Pon of ellexit: ran &= sonatu re tfor exports orilv): /N Date lea - U.S: LWI U , 17 Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Month Day Year COL V) Ar,,thorlv Mad", -7 L Ur e 17)1 DZ /Ye;r 18. Discrepancy I 18a. Discrepancy Indication Space El Quantity' EJ Type El Residue Partial Rejection Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number LL Facility's Phone: L@ Li 78-c. Signature of Alternate Facility (or Generator) Month Day Year - !;C 0 19. Hazardous Waste Report Management Mathod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1. 2. � �Vr1%e =IAA� I3. 14. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the Manifest except as noted in Item 18a prtnledr-lylped Name Signature Month Day Year VY1 (' to // f, ( A) I' t) 1 11 /1 r. � rA M I I -M I A--- /a 10111 / Q� EPA Form 8700-22 (Rev. 3-05)- Previous editions are obsolete. J DESIGNVD ACILITY TO DESTINATION STATE (IF R& WIRED, A 7 i7i O� - 1 4 7f 7 L2t,,3 CAL"0917,R2732 c!4P;_A533;R8 0 L!� L