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j <br /> Please print or type. Fomt proved,OMB No.2050-0039 <br /> UNIFORM HAxAROQUs 1,Generator ID Number 2.Paye 1 of 3.Emergency Response Pion 4.ManilleskIllrecNq Number <br /> WASTE MANIFEST CAR 0 0 0 2 6 6 2 4 7z dla-0097 0 015 2 312 3 'VES <br /> 5,Generator's Nam*and Maung Address XLILMMOALVM I Generators Site Address(it d0arent than mailing address) <br /> MWIGROUM RAW <br /> 505 Hoo O WAY i <br /> TRACT,CA 95377-7217 <br /> Generator's Phone; 209 330-2910' <br /> 6.Transporter 1 Company Name U-8-EPAIDNumPor <br /> VBMJA IM TBCEMV:AL t1?t7dd TKM N I D 0 a 0 6 3 I 3 6 9 <br /> 7,Transporter 2 Company Name U. .EPAID Number <br /> TRISTATE SACT A TRAlti81 i'CO. I lett 0 D 0 9 3 0 3 8 9 8 <br /> 8.Designated Facility Name and MAddressVBDUA RB , U.&.EPA ID Number' ; <br /> 1704w.PURft T <br /> FacIIV6 Ptwna: AZUBAC'A 91702 C A D 0 0 8 3 0 2 34 0 3 <br /> ga. 8b.U.S.DOT Dswa IJon(indudrg proper Sh€piling Nam*,Hazard Cl ,10 Number, 14,Contalrwre 11.Total 12.Unit ' <br /> HM and Pad@ng©roup(€f any)) 13,tHeale <br /> No. type Quantify WINoI. <br /> 1. umt2i%wASTSPAiNrRmA►TmmA � FOOS *1 331 <br /> p x PAIM TIS.Dilt7t'II'>Ki.�,fR! <br /> cmead"J,3,RA I I D F 22 PM S <br /> Z x 2. UK19t9i3,WAR38 FL.A1& A=LI(UM*,as Foos wig 212 <br /> (0 71CYLIM DKWR0PA'[r QQ.3.It <br /> I D 8 260 P Fws DOOI <br /> X 3. [1Nt993,WAWM PLAtw MABLB LIQMG,gLux, DWI 331 <br /> OAMLaffi,�.HYI7I OI'R'BATMVY XAPHTRA <br /> 3,8 I D 1 1 3 P DON <br /> X4- OEN1993,WAXTBP'LA%&(ABLB LIQ o.rxs UO02 D0Q1 <br /> 3t It otE.BII>�},RYLI[tQTRBATffi} VY,ACETCUA I D u 95 P U239 333 <br /> T4,Special Handling nsbuctions end Additional tafonnatian !4E by,W,I,E +Ccnb&d mft1 "* aorrt�t8 <br /> ooiniti�llrt Pit 1069 ! ala b aM �- Btltf#:120W.206781 <br /> .0 M 702 2)MW-,12gSIV,7I604 A: 3)ERQ'.126�A�AQ Mta-171 W:71S09 A:AZEMP1C3 <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the. is of Ns oo ubnment are futiyand acarrately dosAod above by the proper shipping name,aid are dasd W,paciraged, <br /> marked and labeWplacarded,and are In all respects In propercwnMontransport aomMNg to applicable Int*mallonal and national govemmenlal regulations.If export shipment and I am the primary <br /> Exporter,Ice*that the contents of this consignment kwrifoM to the Ierm'Tef the atfad hed EPAAclmowledgment of Consent. <br /> I osrtlfy that the westa mlrlmfzabon statement identified In 4D CFR 262.27{)(VI am a large quanlry genera5x)or(b)(KI am a small quanllly generator)is true. <br /> Gen*ratot&MTor's Pdnt*dfTyped Name Signature Month :Day Year <br /> 7MMA QAI,VANI 014 612 0 <br /> 16,Inteme al Shipments Part� 1loU.S. i 1 <br /> I 1 f xporb frorrr U Of onuylexfC <br /> Transporter sfgnaWre(for exports only): Data leaving U.S.; <br /> 17.Transporter A6mmledgment of Reo*t of Materials <br /> Transporter 1 Printadffyped Ham Signafue hbnth ,D Year <br /> 3MM m ' IO 620 <br /> Tana Pd ypad Name Signawi Month a Year <br /> I <br /> 18,lllsaapa <br /> 18a.Discrepancy W61lon Space Q Qu*nifty Type ❑Residua <br /> ❑Partial Ra)edliDn ❑Fult ReJectbn <br /> Manifest Reference Number: <br /> 18b,Affemate Facility(or Generator) U.S.EPA ID Number <br /> U I <br /> Faaiiltys Phone: <br /> 1110,Pow.. <br /> ANemate Pacitty or Generator) � Month �08y Year <br /> i r <br /> 19.Hazardous Waste Report Management Method Codes(I.a.,cedes for haze ous waste beabnent,disposal,and recycling systems) <br /> HUI <br /> 20,f)ssipnsledl'FFaadklyl Owner or Operator:Certlficatlon of receIIILDf hazardous Ofarials covered by the manifest exoNt as noted In Item 1 <br /> PflutedfTyped Name SIgnawA)t� <br /> Da ryear <br /> L.V <br /> EPA Form 8700-22(Rev.1 -) Previous edi(Ions are obso eta. DESIGNATEF CILITY T4 EPA's d•-MANIFE$T SYSTEM <br /> € <br />