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Please print or type. Form Approved, OMB No. 2050-0039 EPA Form 5700-22 fRev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Pagg 1 of 3. Emergency Responsu pjtp11 ...1 t Rm�l� 4. Manifest Tracking Number V 1007986248 (� WASTE MANIFEST n V SKS 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) ,?elta Water~ Supply ,•: .t�ar.a IN L.Ovoet' ;~tc�f`Y`r�itt�??uiJ CA 9524-i'-01111100 Generator's Phone: 6. Tran 'j�Spg�er t Company,ya �e U.S. EPA ID Number : t I Ni_. 7. Transporter 2 Company Name U.S. EPA ID Number t.!.t_.o-41 NfP1a5 ENV �,�Vt; IME. €�ifdil3cc' 8. Designated Facility Name and Site Address CLEON HARAORS GlR $JbY �IUUNTR I N U.S. EPA ID Number MlilS FPST, 7 MILES NORTH KNU.L.S EXIT 41, C!Ft:. 1-60 KN it_i_S UT 84&1384&13435-884-89151 f, , 3..�r i ii'•��'��. .: tLi .L i. is Facility's Phone: 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes No. Type HM and Packing Group {if any)) Quantity Wt.Nol. ,( ?�.ISA I"AZARTJJ":y VIF 3TC o (PB5�iFQ-NTS CONffAM INAi E1 WITH OIL.) , ham• w z 2. w c7 I 3. 4. I t f 14. Special Handling Instructions and Additional Information ; 14 D A (bit] 66 1962 I DE".3-f}2024 i'C,s3. ned by gener"'atur 1. urife , arjer�y authOrit.' ,), n It i A i t nariskn�c-k.Pr t Brie€ Drs gtib =.; i Y t i rri : #-r-a,tinr 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, marked and labeledlplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if 4 am a small quantity generator) is true. Generatoes1OHeror's PrintediTyped Name Signature -Month Day Year j� 16. Intemational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: Lair 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O CL aTransporter 2 Pritsted(Typed Name Signature 1 Month Day Year [� 1 Y 18. Discrepancy 1 So. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone: w I So, Signature of Alternate Facility (or Generator) Month Day Year a z 05 cq 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be PrmledlTyped Name Signature Month Day Year EPA Form 5700-22 fRev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY