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Please print or type. <br />2 Page 1 of UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST i Al.f.X.1042Z62 <br />Generator's Name and Mailing Address <br />F:Cf;,:iZZlSL.JO Ftii &GRAvL). <br />ifiD3 HijactiRETS 117 <br />SICXKTON, Ck9520:13 <br />Generators PhoneC4:..effAz 7 <br />Transporter 1 Company Name <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />f UIIII typitneu. UIA h10. ZUW-UU <br />0 2 1 9 9 0 4 3 JJK <br />Generator's Site Address (if different than mailing address) <br /> <br />E1iv4RONNEEMAL SERVICES <br />U.S. EPA ID Number <br />Transporter 2 Company Name <br /> <br />U.S. EPA ID Number <br />Designated Facility Name and Site Address . <br />RiAiplOS EKVIROkikleN1-S-1.. SERViCES <br />1515 souni RIVER RD. <br />WEST SACR.441ENTO, CA Ee:435.11 <br /> <br />U.S. EPA ID Number <br />G.ACe".3441:igi:ja <br />Facility's Phonet 1.‘"::7 <br /> <br />9a. <br />HM <br />IX <br />0 <br />LU <br />Lu <br />CD <br />10. Containers 12. Unit <br />VVt.Nol. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Glass, ID Number, <br />and Packing Group (If any)) 13. Waste Codes 11. Total <br />Quantity No. Type <br />i4ON F.C . PDOlS wA,zrE: , DERFelz,-; <br />-L. <br /> <br />el" 0- 3 RE 1 'LOA <br />N mb 1-F-12" <br />wEN-T <br />4 <br />B 0 <br />)1:3/1, 14. Special Handling Instructions and Additional Information <br />PROFI EIA HAWLE7-7:3 TO BE TRAWED AWD USX APPROVED Fve. cof.rmAcrop: Elv,,ip.ow.AENT;„,t. <br />Generators/Offerors printed/Typed Name <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, awl 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 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 />Signature <br />I X \ <br />Export from U.S. Port of entry/exit: <br />Date leaving U.S.: <br />Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />c t <br /> <br />Signature Month Day Year <br />Transporter 2 Printed/Typed Name <br /> <br />Signature Month Day Year <br /> <br />Discrepancy <br /> <br />18a_ Discrepancy Indication Space ri Quantity Type Residue El Partial Rejection 111 Full Rejection <br />16. International Shipments <br />El Import to U.S. <br />Transporter signature (for exports only): <br />Month Day Year <br />121 <br />Alternate Facility (or Generator) <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) <br />Manifest Reference Number. <br />U.S. EPA ID Number <br />Month Day Year <br />I Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. f2. 13. <br />Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Printed/Typed Name <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />Signature Month Day Year <br />GENERATOR'S INITIAL COPY