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Please print ortype_(Form designed for Use an elite(12-pitch)typewrite 6 1.30482 7742-00-1 -Y4 PP W 7;12 2018 Form Approved.OMB No.2050-0038 <br /> UNIFORM HAZARDOUS I 1.Generabr ID Number 2.Page 1 of 3.Emergency Response Phone 4.MarAnt Tracking Number <br /> WASTE MANIFEST �A C o - -, 011848920 FLE' <br /> S eratofs Name and Mailing Address neral�ROSite Axldre v d different than maiirg address) <br /> NI•�rrntain Hnu5R WAtor Treatment Plant <br /> 1.8!14F Neisn Road caMt= <br /> 6. ransponer 1 CoYWrrc •- <br /> U.S.EPA 10 Numbec <br /> w—amental So—ca- Inc <br /> 7.TraItU4 parry <br /> B. signaled Facility Name and Sxle Address U.S.EPA 10 Numbor <br /> :-laan Narhnr[San IU4e I_LC <br /> 1021Rerr-yessaRoad -AbGiiaya-'aiG <br /> FF CA 95133v v <br /> OT Descryfion llncluding rioper'$iypp�rg Name,Hazard Class,ID Number, 10.Containers <br /> 11 Total <br /> rg Gmup(d any)) No. Type GtenL'ry 12 13.Waste Codes <br /> ct RA NAZAROOUS WASTE,SOLIDS,tDIESEL.SOIL,PPE) I Dpli 1 �. <br /> w <br /> 3 <br /> 4. <br /> N.Special Hanclirg krstruc6ons and Additional Infomhation <br /> 1.CH1656800 I Z X 5S <br /> 171tim t ek -shlpptrgn .'ahs. d,Iho, <br /> marked and IabelaNpacarded,.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 Pri nary <br /> Exporer.I certify that thou Contents of this consignment conform to the terms of the atlached EPAAdmovoedgnenf of Cosent <br /> I cedity chat the ivaste minimization salement identified in 40 CFR 262.27(x)(y 1 am a large quantity generator)or(b)(d I am a small quantity generator)is trueGenera . <br /> 1 s nn yped Name gna re n y ear <br /> Q 1 Ile <br /> i6.IntenhaUonal Shganenta ❑Import to U.S. ❑Export from U.S. Pod of entrylex1l <br /> Tran oder si nature for ex only). Dale leaving U.S.'. <br /> w 17.Transporter AcVicrMedgment of Recapt of Materials <br /> Tram i P' d ame nre on y Year <br /> g N 1f(A <br /> Z Transporter 2 Flinted(Typed Name �ay I t w <br /> gnaNre y Year <br /> j78.Discrepancy <br /> 18a.Discreparnry,Indiafion Space ❑Qwnbly ❑iyp- ❑Residue ❑Partial Rejection ❑Fui Rejection <br /> 18b.Alternate Facility for Generator) Manifest Reference Number: <br /> J U.S.EPA ID Number <br /> U <br /> W <br /> Facilitys Phone: <br /> 18c.Signature olAhemate Facility(or Generator) <br /> W Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Imalmont,disposal,and recycling systems) <br /> W <br /> [] 1. 2_ 3. 4. <br /> H141 <br /> 20. f r Designated Faulty r Operator:Caro tion t of hazardous malerals covered by the manifest exceot as rwoed 18a <br /> Prihted/Typed Name Signature <br /> FACILITY <br /> EPA Form 8700-22(Rev. revious edi s o DESIGNATED TO DESTINATIONMATEREQUIRED) <br /> rl.g^ra?.4_...�ygsth�-2?c--. .. ^.rn+ii5s;.��ntYaraK`an+thowa.»rhs6er.o.gr•.r:rci.;..r.;^.r <br />