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<br />Form Annrrivpii C1MR Mn 911Anduile GENERATOR I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />C A C 0 0 3 1 0 8 7 1 0
<br />12. Page 1 of
<br />. 1 -,
<br />3. Emergency Response Phone
<br />4,5-533-0112
<br />4. Manliest Tracking Number
<br />1 2261 9235 JJK
<br />5. Generator's Name and Mailing Address Aft: ;rrisio Hon Commerce Ccnter, L LC , , It •
<br />231 Lafayette Circle, #200 . . 4 . - . i
<br />Tracy CA 94549 .- ci •
<br />e. 1 Generator's Phone: 9 2 5 2 8 3 - 8 7 7 7 :, . ;
<br />I i $ $ 1 ., ).--
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<br />41 ik
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<br />an S'Pq.ertel403/s
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<br />Site Address (If different than mailing address)
<br />H011y Commerce Center, L ..0 -- 20c) 5g,'Holly Drive
<br />TricytqA 96403
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<br />' Transporter 1 Company Name i is: C - ' yi ../..:S;Ii ., -:'• U.S. EPA ID Number
<br />NciviAno tru(k ( ii'Lcy ; ..- A., ...:k..?.:':..i..:::.•'''.. I ), ..,.. !... 1.; s ..,
<br />Transporter 2 Company Narrte % U.S. EPA ID Number l';•-• l'''...;.Y 't, ..., , ,,,• . , I. 1
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<br />' t . ' . r;'../S•114.8 !Vqi;?!).-: . .• . I
<br />Doeignated Facility Nurse and Site Address S,„,!ol' i r r ),1fre..10V•k•4 1° ' U.S. EPA ID Number WOrld-Git-Reeyding. 5.=.4/1").` s{ vr-4A C $1.31-ST $4 k- -.1111g1 •-•i •
<br />2°813-"lamectatO vt 536 5 A., E..iv 6 -4: (e.. '' ' Az Coo a 50 1, q g 0 eompton-CA-90222. Ni,JN"A, A -z. 8 S345
<br />Facilitys Phone: 310-637-44OG. -14o -168 -.2,F188
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes
<br />HM and Packing Group (if any)) No. Type Quantity VVt.Nol.
<br />1NOTI-RCRA Hazardous Waste, Liquid (Oil & Water Mi>cture) 223
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<br />14 Spec Handling InsIntptens and Additional Infonnation
<br />9b.L. - Oil & Water Mixture
<br />ERG # 171
<br />- Invoice Costera Wasli• 6 Envirorolent;a1, Inc.
<br />15. GENERATOR'S/OFFEROR'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, padtaged,
<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 lam 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) (if I am a small quantity generator) is true.
<br />Generator's/Offeror's Printed/T Name SIgnatu, --, Month Day Year _ 1
<br />----/-_,- - --- I-17. 1= (- ''', --.._ .."-1-- I _i-•-:- ,___
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<br />16. Intematonal Shipments '
<br />Import to U.S. Export from U.S. Port of entrylexit
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acinowledgment of Receipt of Materials , , - / .
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<br />Transporter r
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<br />.1 Pripted/Typed Name I. Sktnatur, , • / ' / Month Day Year
<br />7- •
<br />11 i .k ( Ai -)1 I ey , _J.- 71 1-rii i i 4, I (.../... -t,k1 L.(-11 (---: -fi" . I c i.- '‘'' I _. 0(1 `i-1 1
<br />Transporter 2 PnintedhTped Name VOIR, •I
<br />Month Day Year
<br />I I I I 14-- DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy Indication Spate El Quantity ElType ElResidue Partial Rejection LIFull Rejection
<br />Manifest Reference Number
<br />Alternate Facility (or Generator) • U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Day Year
<br />I I
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1.
<br />\ -I\
<br />2. 3. 4.
<br />20. Designated Facility Certifica on of receipt of hazardous materials covered by the maga noted in Item 18a Ove).aperOperat iv
<br />PrintecVTyped Name' Sign lure Month Day Yea;
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. NA ED FACILITY T
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