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` Form Approved.OMB No.2050-0039 <br /> Please pdrd or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man'es TragIRNgmbQr C r, <br /> WASTE MANIFEST CAL 000 286 540 1 510-5A 9-2128 ��v C% .i U 2� � F L E <br /> 5.Gaame and aif n9 Address Generator's Site Address(i different than mailing address) <br /> CSO Mn'_ ate UY11bHr <br /> 3'133 S * f1VV <br /> Slocklon,(.A062 <br /> Generatols Phone: 209-2U-7700 `�gg����P� <br /> r ns er 1 omp ny ame Ut;J QO ue 010 <br /> 4%%EnV�+unnIrawai Solugens <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8. qr�ty Name and Site Address U.S.EPA 10 Number <br /> Ftiglmeay91S Q m11u°.srWh Cr <br /> 1b41tf I'IVEllii(.3 <br /> 775�S 3,2 203 R1V i•3 3001(I�OU <br /> Faa.it's Phole: <br /> ga. 9b.U.S DOT Description(including Proper Shiplass <br /> Shipping Name,Hazard C ,ID Number, 10.Containers Qu Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(,f any)) No. Type Quantity WtNot. <br /> 1. 51 l <br /> a <br /> i <br /> o Non41CR►Hw-artdaus V%ate,Solid (Debris) <br /> Z 2 <br /> W — - — <br /> 3 <br /> 1 1 <br /> I <br /> 4. <br /> 14.Special Handling instructions and Additonal Information <br /> VWM PFS ERG 0 179 <br /> PrOR,v �_) �.: .—✓ ; { EMERGENCY CONTACT JEFF RHODES <br /> 15., GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignrrent 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 govemmertal regulations.If export shipment and I am the Primary <br /> Exporter,l oertify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify Mat the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)oS(b)(it I am a small quantity generator)is true. <br /> enerato s eros not y Name i rgna re' / on ay Year <br /> 16.International Shipments <br /> j ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z <br /> Transporter signature for exports only): Date teawn U.S.: <br /> W 17.Transporter Ar=wledgment of Receipt of Materials11A , a ear <br /> I-- T2 r 1 Printed/Typed Name Signature % on / <br /> o i<CL <br /> U) Transporter 2 Printed/Ty Name^ rgnature c onth Uay Teal <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 /> v <br /> LL Facild s Phone: <br /> 18c.Srgnmuie of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazarcous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1' 2. 3• 4. <br /> I ' <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prime yped N ( Signature Mo lh Day, Year <br /> EPA Form 8700.22(Rev.33-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />