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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST L'A L.0` 2 2 1 9 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) hIT NIXW c-PARENT 2U4zi 8-vINeYARD AVE ��•I(I(r t`.R 917r 8W GPANTLINE RD Generator's Phone: 209 830-8600 TRACY f3A yw 304 6.Transporter 1 Company Name U.S.EPA ID Number 'ONMENTAL SERVICES 7.Transporter 2 Company Name U.S.EPA ID Number WORI-01,61U£. RFCOVr R`+''SYSTEM INC. CA R 0 0 0.1 7 5 4 2 2 8.Designated Facility Name and Site Address U.S.EPA ID Number 6503 WS HIGHWAY 95 ti'J; t5 035 11klR000521146 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes or 1 :'.iN-Af f;'"'A HAZAR00t.I i WASTE,SOLIDS GIL.Y SOLID.PAPER FILTERr;; o Z 2. w 3. 4. 14.Special Handling Instructions and Additional Information EMERGENCY GON AU :CHEIVITREC 1-800424-9300 WOES TERFa11M.: CERES CS NAERG#9131 171 *PROFILE:#901 :.5:623tNRSNIX002 OILY SOLID . PAPER FILTERS * k APPROPRIATE PPE EQUIPMENT 15. GEN ERATOR'S/OFFEROR'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 generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year J 16.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a QTransporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY