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Please print or type. Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �� <br /> WASTE MANIFEST <br /> cAL00 e2 � >� 4 :�© 2459518 021855773 <br /> sV6 "W1IARLEY COOLING TCAAERS Generator's Site Address(if diflerenl than mailing address) <br /> 200 NORTH VAGNER AVE. <br /> STOCKTON CA 95215 <br /> Generatods Phone: 2 0 8 4 0 5 - 3 4 5 1 <br /> 6.Transporter 1 Company Name U.B.FPA ID Number <br /> I umber <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 6.D�g�t � m ter 69VA%GEMENT-KETTLEMAN HE ' <br /> 35251 SKYLINE ROAD <br /> KETTL.EMAN CITY CA 93239 CAT 0 0 0 0 4 6 1 1 7 <br /> Facllitys Phone: 539 380-4a-%411 I <br /> 9,. <br /> 9b.US.DOT Desonpli.(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> Type HM and Packing Group(if any)) No. T pe Quantity WI.Nol. <br /> 48+ <br /> 1JR:11 <br /> O� 1GT�ET't�e4Mt\ Q �1' 4— <br /> A"LU <br /> 2 E sugsraa s soufl 's a, t�?('N,11-1',-1'16 <br /> � LM ZD <br /> 3. <br /> 4. <br /> 14.Speciate Handling Instructions and Additional Information <br /> 1_ Wear 7 <br /> 4ppropriate PPE when Handling Profile # CAt315�85 <br /> Filter Cake containing ahrome <br /> 1s. NERATOR'SOFFEROWS CERTIFICATION:I herebydeclare that the contents of this consignment are fully and accurately described above by the proper shipping name,art are classified,packaged, <br /> marked and labeledlplararded,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 EPAAcknowledgment of Consent. <br /> I certify thatthe waste minimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)('d1 am a small quantity generator)is true. <br /> Generata�s08erD sP.nted(iypedName Signature Month Day Year <br /> s ^, <br /> II'0►4►1;� f�•sPx Gr . U <br /> 16.Inter tional Shipments Impart to U.S. ❑Fa po t horn U.S. Pod of en[rylexit: <br /> ? Transporter signature(for exports only): <br /> Date leaving U_S: <br /> i'X 17.TranspoderAcknowledgmentofReceipt ofMaterials <br /> a Transpo r 1 P nWdTyped Name Sign Month DayYearYear <br /> J <br /> 7lf/ Month Day Year <br /> z Transporter2 PdnledTFyped Name <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number _ <br /> J <br /> U <br /> ZE Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Repaid Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> w t 2. 3. 4. <br /> 13Z <br /> 210.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> PrinW—FnName Signature Month Day Year <br /> EPA Form 8700-22(Rev,12-17)PrevbusefthsafecibsiiIete. SIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />