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c� AOIaI� _. <br /> Plea se-print or type. Form Approved,OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1'Generator ID Number 1`1 <br /> 1 d 3. Phone 4.M'0111983 <br /> it kl <br /> WASTE MANIFEST ` .a L 0 0 f} 2 6- 3 7 9 4 `"`"'��d�' ���1119 8 3 JJ K <br /> 5. "Gei I--('Qmdress maiiingaddress) <br /> 13320-A 21311an"e'vrsi Piave__n..l 200 N.Y-bigner Avenue <br /> Chant K 79277 -? Stockton CA A52it <br /> Generatpor <br /> r''s Phone: 7 0 4 7 2 4 - 1 7 4 3 <br /> s.lffirt@�1 Cpmpany —en U.s�PgID mfr <br /> ff�W1iF''trnr,rorrnerrtal Ser,ir.�*: P. � L C1 0 V2 4 2 4 7 <br /> 7.Transporter 2 Company <br /> �Name <br /> . I U.S.EPA ID Number <br /> B 1�1vTt}�f f;WC•KETTLEMAN HILLS U.S.EPA ID Number <br /> 35251 OLD SKYLINE ROAD <br /> KE'7LEMAN '!TY CA 93230 <br /> Facility's Phone: 519 385.0208 C A. T 0 0 0 C 4 B 1 1 7 <br /> ga, 9b.U.S.DOT Description(mduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(8 any)) 11,Total }2.Unit 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. I !vironrnef azar taus bLit-stance,moil Tsema ,Elir 1 <br /> o uh 7 f ARS..,,uic, T <br /> CP.A. Y <br /> t7 <br /> 3. <br /> 4, <br /> 14.Spec at Hazdl�n n�splr oa C3fLI � aUon <br /> Filter cake sludge <br /> Wear Proper PPE krhan handling <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,amt are classified,packaged, <br /> marked and iabeledf oacarded,and are in all respects in proper condition for transport according to applicable intemationatand national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment confy rn to the terms of the attached EPAAcknowledgment 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)IN am a small quantity generator)is true. <br /> Generatols(ORerors PrintedRyped Name Signature Morph Day Year <br /> 16.International ' ❑Im <br /> f. port to U.S. _ ❑Export from U.S. Port of enlryAmi <br /> ? Transporter signature(for exports only): Data leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> � Transporter f Printed/Typed Name ! F Signature Montl Day Year <br /> W Transporter 2PrintedlfypedName Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceQuantity ❑Type <br /> ❑Residue ❑Partial Rejection El Full Rejection <br /> Mani Reference Number. <br /> 18b.Alternate Fadlily(or Generator) US EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> F18c.Signature of Aitemate Facility(or Generator} Month Day Year <br /> 4 <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 �\15/ 1 <br /> 2 3. 4. <br /> 20.Designated Fadlity Owner or Operator Certification of recetpl of hazardous materials covered by he manifest except as nded in Item 18a <br /> P' Name 'na re � <br /> Mworith <br /> EPA Form 8700-22(Rev,12-17) Previous edons areo&,olete. DESIGNATED FACILITY TO GENERATOR <br />