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Please prttit or type.(form designed for use on elite(12 pitob)typewriteu4 ���}¢} 27s7 �; 039 <br /> Sam <br /> UNIFORM HAZARDOUS 1.Generahx ID Number 2.Page 1 of 3.Emergency Response Plane 4.ManffW Tracking Number <br /> WASTE MANIFEST 7 011848922 FLE <br /> 5.Generator's Name and Malting Address nerator§Si ress( i t than malling address) <br /> Mountain House Water Treatment Plant <br /> 1'3045 Kelso Road SPATE <br /> rGe e�as !ii <br /> 6. rarsporter 1 Company Name U.S.EPA ID Number <br /> `lean Hat-bus Fnvirrmw%erv-0 Ina. -? <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desiignated Facility Name and Site Address U.S.EPA ID Number <br /> COLES ENYMNMENTAL/BAKERSFIELD TRANSFER ��`� Q v �$ 2� S S <br /> 1620 E.BRUNDAGE LAME <br /> ld-CA 53307 <br /> tl <br /> ga 9b.U.S.DOT Desai= i acing roper ipping Name,Hazard Class,ID Number, 10.Contatiners 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> 1. <br /> o NON RCRA HAZARDOUS WASTE,LIQUIDS.r��sEL,WATER! 242 <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> i.Sepal 3a1$�Instructionsl a Ad?rtional Information <br /> W e)(o 5�t i <br /> r0ntl`3;'.t retained bx OervaVor Oonfer5 aaercv authOrtty on IDltlal tralscele!t0 add or sub =tai add cinaf transpoiler5 on ceneraw6P <br /> 15. GENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.K export shipment and I am the Primary <br /> Exporter,I certify that the contents of this corwgnment conform to the terms of the attached EPAArknowledgment 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( (If I am a small quantity generator)is true. <br /> s yped Name ana reMonth Day Yew <br /> V <br /> 1 16.International Shipments <br /> t` Import to U.S. 0 F_xport from U.S. Port of entry/mat <br /> Z <br /> Transporter s' lure for exports onl : Date leaving U.S.: <br /> 17,Trarspater Ackro0edgment of Receipt of Materials <br /> Trainporlar 1 Nn `Typesd Name on ay Year <br /> a w4- Y \W CSLO.o �b t� <br /> ;�� <br /> Z Transporter 2 Pdnted/ryped Name Signature Moniy ear <br /> i <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parbal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(o Generator) U.S.EPA ID Number <br /> U <br /> Q <br /> �+- <br /> FadlRys Phone: <br /> W 18c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> L <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18e <br /> Printed(Typed Name Signatu Month Day Year <br /> 7" 0 05115 <br /> EPA Form 8700-22(Rev. 5) Previous editions are obsolete. DESIG D FACILITY TO DESTINATION STATE(IF REQUIRED) <br />