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Please print or typo, (Form deslaned for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATEIF REQUIRED) <br />Otrder"i ftswC <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />CAf _OW47Aa65 <br />CA <br />2. Page 1 of <br />2 <br />3. Phone <br />�°ar USA 1f. <br />4. Manifest 7rackIng Number <br />0 7 JJ K <br />WASTE MANIFEST <br />Sm 53`5.511 31 <br />5. Generator's Name and Mailingg �Address Generator's Site Address (if different than mailing address) <br />Fntuiswo Bsttdim Sae• Va13ay Stu <br />2757 BOMNO WAY <br />STOCKTON,21q <br />� <br />.'6543 <br />Generators Phone: <br />6. Transporter 1 Company Name <br />UNIVAR USA INC` <br />U.S. EPA ID Number <br />CADDID925376 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />ENGLUND EQUWMENT CO. <br />AZD%24035H6 <br />'y <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />r.) <br />US ECOLOGYBRATT'Y <br />1WT'3l002000D <br />", <br />PO BOX 578, BW 960111Q S OF BE 477Yt. <br />R ATTY. NV. 89003-057 <br />Faclll s Phanw (8M 239`3943 <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNoI. <br />NA3077, Hazardouw walic, &did, n.a&. (Lmd), 9. P[3 IQ, <br />b008 <br />0311, <br />(ERG�-171; <br />^ <br />181 <br />z <br />2. <br />L <br />c� <br />3. <br />4. <br />14. Special Handling Instructlonsand Additional Information <br />1.070128303-13077(Lead and Acid Debris) <br />PLACARDS PROVIDED BY TIM CARRIER FIII'PER �' O DRIVER SIGNATURE <br />****'ER [�Ai.i.prr MUST IDENTIFY VNIV 5A A5 CfIS'iRANT {1^ONTRAGT <br />569 ** <br />15. GENERATOR'SIOFFEROR'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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (H I am a small quantity generator) is true. <br />GeneratoeslOfferoes Printadrryped Nameigm tuna <br />Month Day Year <br />1 �il.t <br />- <br />-1 <br />1.- <br />16. Inte ational Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />0 <br />CL <br />Tran spprtar 1 Frintad(Typed , �� Sin <br />!�C/ � <br />Mon pDa ear <br />f <br />QTransporter <br />2 in}adLLrned Name J Signature <br />7 <br />Ray Year <br />1,9 <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantityyp <br />❑ Type El Residue <br />El Partial Rejection <br />Full Rejection <br />Manifest Reference Numrbec <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />w <br />1 Se. Signature of Alternate Faci 1ty (or Generator) <br />Month Day Year <br />!Q <br />Z <br />v519. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3. <br />4. <br />a <br />20. Designated Facilily Owner or Op tar, Cerfificaf n of receipt of hazardous materials covered by the manifest except as d in Item 18a <br />Pnn yp a Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATEIF REQUIRED) <br />Otrder"i ftswC <br />