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Form Aooroved. OMB No. 2050-0039 <br />nee= <br />A <br />pin! It vi iype. <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />C A L 0 0 0 4 4 4 8 3 3 <br />I 2. Pap 1 of g6EmrNigsgoiiise Phone 4. Manifest Tracking Number <br />022582650 JJK <br />lieted[litnrgeMittgs <br />At KELLY D <br />5701 PROMONTORY PARKWAY <br />TRACY CA 95377 <br />Generator's Phone: 2 0 9 3 0 5 - 0 1 7 1 <br />orktteiNtraglifttgian mailing address) RRER ari <br />2325 W. LOUISE AVENUE <br />MANTECA CA 95337 <br />I <br />Transporter <br />16. <br />X'A BNibnbei Name <br />1ORAVI 364 h NTAL SERVICES 8 1 3 7 7 8 6 4 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8.geduarifil FfiljamalihWess. LANDFILL <br />U.S. EPA ID Number <br />19536 S. AVE IE <br />YUMA AZ 85366 <br />Facility's Phone: 928 341-9300 <br />1A Z R 0 0 0 5 0 6 9 8 0 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers it. Total 12. Unit 13 Waste Codes <br />NM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />ce iNon-RCRA Hazardous waste, solid (Oily Soil and Rocks) 611 <br />0 <br />g 2. CF ti 000 p <br />z w <br />tu Von-RCRA Hazardous waste, solid (Oily Soil and Rocks) 611 <br />0 <br />1 ,t41‘ 8°(2 P <br />3, <br />4. <br />14. Special Handling Instructions and Additional Information 1) qty Soil and Rocks ( 2._ x ) 2) Cry ScI <br />(---lan 10 <br />locks ( 1x55 phi <br />( (X) . <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid 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 tam 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 that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am quantity gen ).is true. <br />Genera r'slOfferor's P ' led/Typed Name 4,-) Signature Month Day Year <br />AV' 1:77e- CIV i /202 I t / I S I 131 2-1 <br />_j 16. Inte ationa hipments Export from U.S. Port of entry/exit: <br />I-- Import to U.S. <br />Transporter signature (for exports only): Date leaving U.S.: <br />14 17. Transporter cknowtedgment of Receipt of Materials fRANSPORTE TraN1 1 ted/Typed Name e r Sign <br />-0-\ As -rut-) I <br />Month Day Year <br />f (LA.)I 5 1 1 3 1 al <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I I -4-- DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Indication Space Quantity LII Type El Residue U Partial Rejection LII Full 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 Re Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />} <br />j3) 2. 3. 4. <br />20. Designated Facility er or Operator: 'fication of receipt of hazardous materials covered by the manifest exc- . cted in Item 18a <br />Printed/Typed Name <br />t / <br />Signatur: Month <br />/(A <br />,rcr:( r• ITV TA enAl- — AR A KIICCCT ...,narsil <br />I <br />0 Year <br />QVC PRA <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. LJCJIUNA I cu r Dp..1 y v