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MR'S,4.,r V'.-�!Pt Jn L`r• tJ�`..CI L <br /> Please print or type.(Form designed for use on elite 12-pftch)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 0 17 61517 5 J J K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(f different than mairing address) <br /> UnIenown Drug Lab Operator C/O DTSC 99 Frontage Road and Sunny Road <br /> P.O. Box 806 Stocidon,CA 95215 <br /> Sacrarnefito,CA 95812 <br /> Generators Phone: <br /> -- - ame <br /> 6.Transporter 1 Company - U.S.EPA ID Number <br /> - <br /> PARC Specialty Contractors CAR00015 885 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Steric cle S ecialt Waste Solutions Inc. <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RHO-CHEM,LLC CADOD8384432 <br /> 425 Isis Avenue <br /> Inglewood,CA 90301 <br /> Fad 6tys none: <br /> 9a 9b.U.S.DOT Desaipfion(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(f arty)) No. Type Quantity Wt.Nol. <br /> L <br /> o X UN2811,To)dc Solids,Organic,N.O.S.,(Hancat),S.1,PG II 1 DF 10 P -352 <br /> z 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> ERG#154 ERG Book in Vehicle.Wear appropriate PPE when handling. <br /> 1(1x5) <br /> Job#368518 Clue#2018-0&005 <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 labeledlplacarded,and are in all respects In proper condition for transport according to applicable Intemational and national govemmental 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)(d 1 am a Fall quantity generator)is true. <br /> Gene Offerors Printed/TyName Signature Month Day Year <br /> .1 16.Intemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Ye <br /> CL <br /> aTranspo r2Printed/Ty IN Sig lure Month Day r <br /> tY ��F-- <br /> 18.Disc apancy . <br /> 18a.Discrepancy Iridication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 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 /> Printeffyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 13146.0572 <br />