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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST i r, JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ?,W=Y LUBE VZ)_ <br /> "M E KETTLOWN RD <br /> LODI CA 15240 <br /> Generators Phone: Q <br /> 4Q 41' <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> n 1 n <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 /> s,IEW—NS WATER TECHNOLOGES CORP <br /> 5375�OI.1TH BOYLE AVENUE <br /> c.os 1sNOEl..ES CA ri(X'`fa8 <br /> Facility's Phone: rrIT, >^ A Ia i; r' <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nd. <br /> 1. <br /> f<Ot+RCRA HAZARDOUS WASTE, SOLID (OII.'(A8S(,1f1HFFr0 <br /> F) 11114 <br /> Z 2 <br /> LU <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 'i�RGFlI,E#981 4P 15? 3 fall. 1.10% ABS;0RBFNT f,&6X)% -44M 101IM109`APPROPRIATE PER'ONAL PROTEC f1VE <br /> FOI_4PK-'NT <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)(f I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature r�, Month Day Year <br /> 1 \\ l <br /> 16,, a nal Shipments <br /> 1= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Neme Signature Month Day Year <br /> O <br /> zQ Transporter 2 Printecirryped Name Signa4ue Month Day Year <br /> tY <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(o.Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> C3 <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> F, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> � <br /> 1. 2. 3 4. <br /> 20.Designated Facility Cwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed;Typed Nane Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />