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<br />Please print or type. Form Acoroved. OMB No. 2050-0039 -4 GENERATOR UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator INumber
<br />C A C 0 0 3 1 0 El. 7 1 "0
<br />2. Page 1 of
<br />1
<br />3. Emergency Response Phone
<br />416=633-0112
<br />4. Manifist Tracking Number
<br />9 2 2 6 1 9 2 '7 7 JJ K
<br />Generator's Name and MaiiMp Address , Aft Tilde $ 15#5 Generators Site Address (if different than mailing address) flatly t_,ommetce (-enter, 1..1.(. Hon Conxnerce Centel', L .c
<br />231 Lafayette Circle, t$200 20r-400 Holty DOVE:
<br />Tracy CA 94549 '4! , fit 96403
<br />1 A ' ,.,• • ',
<br />e .1 • el. AitAi Generator's Phone: 9 .25 • 2 8 a 8 7 7 7'd
<br />'' 1 ,, • I 4
<br />Transporter 1 Company Name ., . US. EPA ID Number
<br />0' . '
<br />( V ( \ 4C \ ( l i ('N ( V'; . ; I I c A ,,r, _eiltr6q -.;,/.?
<br />Transporter 2 Company Name U.S. EPA ID Number
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<br />:,.- .t.... - .. ,.. i Name rid Site Add s .1 1 . v . 2 '..f ,i.. U.S. EPA ID Number
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<br />.11 ' 4-: ' • . . - 00#' ' . --
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<br />a.2) -,:..-,,._. Facility's Phone: t 1..::i_ .,,.. '-.1-C.-&-T--CLA-4",1-0--1.---?
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<br />1,40 ,g ., • •
<br />ga. 9b. U.S. DOT Description (including Proper Nipping Nime, Hazard Class, ID Number 7t7 ' 10. Containers 11. Total 12. Unit 13. Waste Codes HMand Packing Group (if any)) No. Type Quantity Wt.Nol.
<br />. . . iNon-R ORA Hazardous Waste, Liquid (00 & Watof Mixture'l 223
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<br />14, Special Handfing irittuftionp arrcil, ilitienplIntintienti
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<br />, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, art 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 EfA 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) (ifl am a small quantity generator) is true.
<br />Generators/Offeroes Printed/Typed N e Signature . .. Month Day Year
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<br />International Shipments
<br />Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.: 1TRANSPORTER Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed Name Signah.,.. Month Day Year
<br />',.. t , - ( V, ''' i• il‘ 4 tr' I 1"...........-- 13 1 -5 / Ie (
<br />Transporter 2 Printed/Typed Name Signature Month Day Year
<br />I I I I *---,- DESIGNATED FACILITY Discrepancy
<br />18a. Discrepancy Indication Space LII LII]r -.: ( Quantity Type Residue Partial Rejection Full Rejection
<br />G )
<br />Manifest Referencell Ile( )
<br />18b, Alternate Fdcility (orleneratdr)' ' " \ U.S. EPA ID Number
<br />Facility's Phone. I
<br />18c. Signature of Alternate Facility (or Generator)
<br />...
<br />Month Day Year
<br />I I
<br />Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1 j f i.":.• 2. 3. 4.
<br />Designated Facility Owner or b-perator: -deltlication of receipt of hazardous materials covered by the manifest exceptes ncted In Item 18a
<br />Printed/Typed Name / Signature )
<br />\\ Month Day Year .. ,
<br />1 I. ..- ' i ( s '1' ( I r i ' I 1 •
<br />
<br />TRANSPORTER COPY EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.
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