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i <br /> Please print or typo.(Form designed for use on elde(12-pitch)typewriter.) Form Approved.OM8 No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generalot IO Numbor 710,11 <br /> f 3.Emergency Response Phone 4.f anifest Tracking Numberr <br /> WASTE MANIFEST CAR000220046 909--984-9984 011828875 FLE <br /> 5.Generalor s Name and Mailing Address Generator's SO!Addross qt different than maVing address) <br /> CALIFORNIA HEALTH CARE FACILITY (0'155'1) 7707 SOUTH AiJSTIN ROAD <br /> 7707 HOUTH AUSTIN ROAD (attn: 11. Medlin) STOCKTON, CA 95215 (attn: Hel,tie Medlin) <br /> STOCKTON, CA 95215 <br /> Generators Phone: 467-7904 <br /> ransportet i Company area U.S.EPA 1D Numbor <br /> XNpUSTgIAL WASTEUTILIZATION, INC. CAD980585293 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> IreM el'A'.0 IveC G ihL <br /> 8,Designated 1`401Ay Name Site Address U.S.EPA ID Number <br /> RECICLADORA TEMARRX DE MEXICO,S.A. DE C.V. <br /> CARIt.,FED NO 2 NEXICALI—TI�7UANA Kbf 121 <br /> 8AN PABLO TECh7z M344m <br /> FiaiVs Phonal; -1462 MXC130619 1 <br /> 9a, O U 3 DOT DosidpGon(including Proper Wong Nam,Hazard Claw ID Nwnber, 10.Containers 11,Total 12.ihilt 13:Waste coos <br /> NIA No, TYPe; Quantity WOW,, <br /> and Par�inp Gronrp fol eoY)1 <br /> 0#3175 Wants Bolide containixsg flammable l quid oD001 F003 352 <br /> X n.o.0, 01cohol/acetone) , 4.1, PdII ►►''''))V ' l � - <br /> 2. <br /> 3. <br /> 4. <br /> 14.$pedal Handling instructions and Addi6wal Information <br /> 1) rage,/solvents-app# R18-9201; ERG #t 133 <br /> I <br /> j S-S ?20 0 'zy90 V%M, <br /> 16. OENERATOR'51OFFERCR'S CERTIFICATION:i Hereby dedare tot the wtents of this b*340enl ere hdlg and aceuralely described above by the proper shipping no and are dassited,packaged, <br /> madced and labekdtplacarded,and are in a1 respects to proper condition tot transport according to Bpo,5 64(nlgmaf oriel Arid Ifatii>nai govEmmenlal regulations.H export ah(pmont and f am One t�r6nary" <br /> Expodor,l ce+tity that the contents of gds consignment conform t9lhe tomes of attached EPAAdsn'k1gment of Consent. <br /> 1 cettify that the waste m6nrnization ttatement Identifiied in 40 CFR 2ti227(a)(d 1 am a large quantity getoralor)a(ti►INi am a swan qu4n0ty,ge tor)is two. <br /> Genotaloestolofoes PdntodfTy a s nor urMonth Day eat" <br /> 16.INemawal SN pnnen s 1�I <br /> ❑Import to U.S. N Export from U.S. Port of en Xit <br /> Trans t s aturo fore ds Dale lea U.S.' --' <br /> 17.TtanspadetAcktcmtedgment of Receipt of Materials <br /> Tra porter '!d: yped ams :Rt�� ayear <br /> - ' � � U606I <br /> Transporter 2 Print0fyped Namenor re ay ear <br /> < 4 1y / <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space F1 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejectbn <br /> Manifest Reference Number: <br /> f8b.Alternate Fanlity(or Gonwalor) U.S.EPA ID Number <br /> C! <br /> ROMA Phone: <br /> ® 180.Signature o(ARornato Facfify(o(Gonerator) Month Oay Yoar <br /> R19.Hazardous Waste.Repott Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and iec),cling systems) <br /> 1 �- � 2 3. d. <br /> { <br /> 20;Dostgneted facihty"nqf or Operator:Ceifi kattorn of recelpl of hazardous materials covered by the rnanitesl except esrel ."POT:18a <br /> PdNeName S nature Month 0 Year <br /> EPA Form 8700.22(Rev.3.05) Nevfou litions are obsolete. DESIt3 ATPD FACILITY TO DESTINATIQN STATE(IF REQUIRE ) <br /> t <br />