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Please orint or him. (Form desiarled for use on elite (12 -Bitch) WDewriter.) <br />/6000 7z9O s <br />Form Approved. OMB No. 2050-0035 <br />EPA Form 8700-22 (Rev. 3-05) PreWoUs edmoldle obsolete. <br />DESIGNATED FAel-ITYA` DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Pegs 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />CA L o o o 3 4 3 9 4 <br />Bao 424.9300 <br />009816452 J J K <br />Genemtoes Name and Madkg Address Generator's Sae Address (d different than mailing address) <br />FERGUSON <br />530 PORT OF STOCKTON ST <br />STOCKTON CA 95203 <br />Generatols Phone: <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />FREMOUW ENVIRONMENTAL SERVICES INC C A R 0 0 0 1 7 1 0 1 7 <br />Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENVIRONMENT <br />8 Designated Fad* Name and Site Address U.S. EPA ID Number <br />CLEAN HARBORS <br />1021 BERRYESSA ROAD <br />SAN JOSE CA 95133 <br />FadWs Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number. <br />1, Cectatners <br />11, Total <br />12. Unit <br />13. Waste Codes <br />N.. <br />T,;, <br />HM <br />and Packing Group (K any)) <br />Quantity <br />WINol <br />1RQ UN 1760, WASTE CORROSIVE LIQUIDS, N -O -S.. <br />141 D008 0002 <br />X <br />(RINSEWATER WITH LEAD). 8.11(D002) <br />I <br />f� i <br />0 <br />LU <br />X <br />a <br />3. <br />4. <br />14. Spada] Handling Instructions and Additional Information 1)CH 1103008 / Rittsewater with Lead / Corrosive ERG#171 <br />'teadf_1—� n � )c Z x fivtP 4s <br />td ray l I <br />tIA'VDr ra c TO BE 40HR TRAD.'ED AND USE PPE.. ER CoD <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurately desaibed above by the proper shipping name, and are classified, packaged, <br />marked and tabe)ed'pacaroed. and are in all respects in proper condition for tiaispor, according w applicable international and national governmental regolat". If export sMpmert arta I am the Primary <br />Exporter, I certify that the contents of this corsigrment conform to the terns of tie attached EPAAcknowledgrnent of Consent. <br />certiy that the waste mnimizatcn statement identified .n 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (if I am a small qWlity generator) s Vue. <br />st erors PnntedlTyped Na Sgrtatiue Monc, Da, -,-,r <br />2 r vF 01 0� L <br />.s <br />F <br />16. Intematiorul <br />❑ I b U.S. ❑ Export from u Pat a enxit —.-- <br />= <br />Transporter signature (ter exports only): Date lea U. 5.. <br />17. Transporter Admowledgment of Receipt of Materials <br />T 1 PrintedrTyped Name Month Day Year <br />10 rle 1 101 10 1A <br />Transporter 2 Prin <br />Nam Month Day Year <br />18. Discrepancy <br />18a Discrepancy Indication Space ❑ ouantity ❑Type �I Res.due ❑ Partial Rellection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Abemate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Zai <br />FaobysPh— <br />18c Signature of Aftemate Facility (or Generator) <br />Day Year <br />aW <br />Y <br />I. <br />y19. <br />Hazardous Waste Report Management Method Codes (.e-, coon for hazardous waste treatment aisposai. and recydmg systems) <br />2 <br />3 <br />.t <br />26. Designated Faahry Owner or Operator Certification of receipt of hazardous materials covered by the manifest e!X as rided in sem 18a <br />PrVlted/T Name Signah Month Day Year <br />+III <br />Q <br />EPA Form 8700-22 (Rev. 3-05) PreWoUs edmoldle obsolete. <br />DESIGNATED FAel-ITYA` DESTINATION STATE (IF REQUIRED) <br />