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S # 22911721:3 <br /> Please print or biop <br /> m Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 13.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CARO@55301 l-.3f�'t-rp';t1 'f.,il SKS <br /> rrr�f:y ("�i�irytiat <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) u nu <br /> .3450 Puto Plaza Pkwy <br /> l )l q <br /> TPf)r,f CA 95375--00100 <br /> Generator's Phone: i 6 3Q1-:3�aEF? <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> :1.N SYSI-ENS INC T X RIP00081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> T14I RMO FLUIDS INC <br /> 12533 SE CARPENTER DR <br /> CLAf14AMAS , OR 97015--8964OR9 <br /> .tID3. 781-461 F, 1C 0002`1 197 <br /> Facility's Phone: �,• <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total <br /> HM and Packing Group(if any)) No. Type Quantity 12.12.Unit <br /> t 13.Waste Codes <br /> 0 1. NON-RCRA HAZARDOUS WASSOLID 2230 (DRAINED/UNDRAINED 0SED 61L FILTVEk RS) <br /> Z 2. - <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information T13D Y TPO 80.739539 T R 34107 201931 CSG:24 <br /> H E'MERGENC,Y#800--458-1760--CHJ/SK/TFI-C:antract retained ltY tic;r,F;r:-s ;;r comers a ncy -Ithori y <br /> r'T` •' y.}yy a t'o .I ,,P 1 •�1 - _ n r .. <br /> attalf <br /> 15. GENERATOR'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, <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 EPA Acknowledgment 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)(if I am a small quantity generator)is true. <br /> Gen_erato[s/Offeror's Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> IX W 17.Transporter Acknowledgment of Receipt of Materials <br /> t- Transporter 1 Printed/Typed Name Month Day Year <br /> � /� Signature -, <br /> Transpdrter2PrintedlTypedName Signature', Month Day Year <br /> 9 <br /> 18.Discrepancy <br /> 185.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F}-- 18b.Alternate Facility(or Generator) <br /> J U.S.EPA ID Number <br /> U <br /> 24 Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2• 3• <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name (� Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />