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Please print or tvoe. <br />SK SIS 1 A# 2EG40 7 1443 <br />Farm Approved. 0Mf3 No. 2050-0039 <br />Number <br />EPA Form 8700-22{{�Rev. 12-17) Pfevious editions are ab�pWe. v t ' � DESIGNATED FACILITf TO GENERATOR <br />117482522 810215 <br />UNIFORM HAZARDOUS <br />"Generator ID Number <br />C�Ir•������ �, c"� <br />2. Page 1 of <br />1. <br />3. Erne e �y Res gee Ph <br />1—•���fr' e%�1ZE <br />4. Manifet T <br />10036,13,%1006 SKSWASTE <br />MANIFEST5. <br />Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />C�.ty Of Stockton Delta Water'Treatment I�la�st11373 <br />N Lower Sacramento <br />LODI CA 95242-9545 <br />Generator's Phone: 209--937-8762 <br />s. Tr§90 Onmp�yL"- SYSTEMS INC <br />U.S. EPA ID NumberfXR@00@81a05 <br />7. TranFsplo`rteer 2 CCo�m'ipEanny Naamee <br />U.S. EPA ID Number <br />CLEAN HARBORS ENVIRONMENTAL SVC INC. <br />MAD039322250 <br />8. Designated Facility Name and Site Address GLEAN HARBORS 'SAN JOSE <br />U.S. EPA ID Number <br />1021 BERRYESSA ROAD <br />SAN JtIa�I; CA 95133#08-441--0962 <br />CAD059494310 <br />facility's Phone:9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />1t. Total <br />12. UnitHM <br />Waste Codes <br />No. <br />Type <br />and Packing Group (if any}) <br />Quantity <br />w1.1Vol.13. <br />1 HAZARDOUS WASTE', SOLIDS, (OIL. <br />DM <br />P <br />223 <br />0 <br />�DE SIS) <br />�Z <br />2. <br />rU <br />4. <br />14. Special: andling Instructions and Additional Information TSD:SJ 79993937 Cl3396124H <br />EMERGENCY#800-468-1760-Cil/SK/TFI-'Contract retained by generator <br />confers a entwy author! <br />on i 3 ia1 r r• r a <br />I15. <br />GENERATOWSIOFFEROR'S CERTIFICATION: I hereby.declare that the contents of this consignment aro fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledfplacarded, and are in all respects in proper condition for transport according to applicable international 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" EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) jif I am a large quantity generator) or (b) (if I am a small quantity <br />erator) is true. <br />Generate sfOffe pGs.ArmtedlTyp�d Name Signature <br />Month Qay Year <br />,j <br />H <br />16. Intema i0nal Shipments <br />❑Import to U.S. ❑ Export from US. Port of entry/exit: <br />Transporter signature {for exports only): Date leaving U.S.: <br />w17. <br />Transporter Acknowledgment of Receipt of Materials <br />cc <br />Tra rter 1 PrintedlT d Name Signature <br />Month Day Year <br />6 <br />IL <br />Z <br />Transporter 2 P ntedlT arae Signature <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication $pace Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA 10 Number <br />UU< <br />Facility's Phone: <br />w <br />18c. Signature of A€ternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste ReportM a emen M thod Codes (i.e., codes for hazardous waste treatment, disposal and recycling systems) <br />w1. <br />2. <br />3.20, <br />Designated Facility Owner or erat - Certificatio of receipt zardous materials covered by the manifest except noted in ItemPrintedlTyped <br />NamePW <br />(A V-A �-- C--// Signature <br />th D Y <br />EPA Form 8700-22{{�Rev. 12-17) Pfevious editions are ab�pWe. v t ' � DESIGNATED FACILITf TO GENERATOR <br />117482522 810215 <br />