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912366-16 — t 4 . 3635. ,3 :�� X2355036 <br /> ' <br /> Pie se <br /> P,r" <br /> .type.(Farm designed for use on elite(72-pitch), �y ,) 1G^. 1. 2 � /-� 'C FormApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'Generator ID Number ,, 2.Page 1 of 3:Emergency Response Phone 4.Manifest Tracking Number <br /> ' �VNASTEMANIFEST cALOFk0433752 1 (077) 577-26691000128570; DAT <br /> S.Gtv2rators Name and Malirg Address - 'W _ r Generabis She Address(ifdifferent than mailing address)- - <br /> D§ � Sloit (Teafiag Saruyces <br /> 704 I as nal Part Drim 106 h6ustriel Pyre Drive <br /> Generators Phone: HanteW CA 94237 (209)024-3942 IWM CA SUIT (209)026-3042 <br /> 6.Transporter 1 Company Name _ U.S.EPA ID Number <br /> 21st Century nvir'on6ental HanaTaenen4 of California LPCRR000210617 <br /> 7.Trensponer 2 t.o any Name U.S.EPA ID Number <br /> Z 67Z <br /> a.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 2�ST CEMY EMI0=fl GC'1,HIE03T OF CEURf'A, LLC <br /> 2094 G2M DZUE EAST <br /> Faoliys Phonei 1 575-2760 I .NVII980895330 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Harald Class,ID Number, 10.Containers - 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Ouanty WINoI. 17.Waste Codes <br /> do ' WHO lLUSTE FLZE UE LIDUIDS, H.O.S. (finual S9IBITS, 9001 D010 F003 <br /> R9 6OWNE) 3 PHI 60(D501=10OLDS) OPi 30(3 P <br /> w 214 <br /> z; LM-HCCR N,A7MMS LASTE, LIQUID 10ILY UTERI 223 <br /> p. DN P <br /> 3. <br /> 1. <br /> r <br /> 4. <br /> '14,-Special Handhrtg Instructions and Aulditional Information <br /> (1).743122-00 - EM201 HI)lED 54LOECTS 121 741190-00 OILY LATER <br /> -IS.' GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents oftisconsignment ate kdry and acarately described above by the proper shipping name,and are cassilled,packaged, <br /> ' marked and Iabele 11 lamnfad,and are in all respects in proper condition for transport according to applicable intematimraland national go emmental regulations.If export shipment and I am the Primary <br /> Exposer,I certify that the contents of this consignment conform to the temp of the atlached.EPAAdTaMedgmenl 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)(III am a small quantity generator)is true. <br /> Gene tor. OSemrs Pimman r arae signatu Month Day Year <br /> U <br /> F <br /> J 16.International Shipmen El Mpart b U.S. ❑Expon from U.S. Pon of a;nu- <br /> 'C <br /> Transporter signature(far exports only): Date leav' U. .: - <br /> w 17.TransponerAdmoWedgment of Receipt of Materials <br /> Transporter 1 Printedrrffypred Name Sign Nre pQ Month Day )Year <br /> �-�vC 1" I lI� CVS ,?A 3 Ly / _ <br /> Transporter 2 PrintedlTyped Name Sgnatum Mont Day Year <br /> } 18.Discrepancy <br /> tea.Discrepancy Indication Space ❑ Owfity, ❑Type ❑Residue ❑Penal Rejection ❑Fug Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Sgnature ofAllemate Facility for Generator) Month Day Year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes fi.e,codes for hazardous waste treatment,disposal,and rarydmg systems) <br /> 1. I 2. I 3.. 4. <br /> 20.Designated FacikqOwAff or Operator.Cenfttbn of receipt ofhazardousmaterals revered by to manifest except as n Item 18a <br /> P' yped Name Signature Day Year <br /> A - -f r <br /> EPA Form 700.22(Rev. 5) fepus edNonsa obsoete. DESIG _ STATE(IF REGUI D) <br /> Ann F, 9!116 <br /> 12376.0125 <br />