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�R <br /> Please p'mit or type.(Form designed for use on elite(12-pitok)typewrite4 :1804132787 iq- -2; • 8 � 039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 <br /> 011848922 FLE <br /> 5.Generators Name and Water <br /> glAddress nerator§S rens( i than malling address) <br /> Mokeit:?tn i IJUse SRater Treatment Plant <br /> 18f145 Kelso Road GA;ygE <br /> 140till 9r" ' <br /> Generators:- <br /> ransporter I Company Name U.S.EPA ID Number <br /> 'llean Harbors Ervirfmoiertai fiey,rices.Inr, _ y •t <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> COLES ENVIRONMENTAL/ BAKERSR ELD TRANSFER C A i D O v 2 8 2 i 8 3 <br /> 2520 E.BRUNDAGE LANE <br /> Id.CA 93307 <br /> tl <br /> ga 9b.U.S.DOT Desai0udng roper tipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity Wt.Nol. 13.Wade Codes <br /> 1. <br /> Ce NON-RCRA HAZARDOUS WASTE,LIQUIDS.(DESEL,MATER! � a <br /> z 2. <br /> w <br /> c9 <br /> 3. <br /> 4. <br /> 1$e D2u clions and�1I Additional Information <br /> V-VS123 <br /> Contract retained bit oatlemtor oonfcr5 memo authoritU on Initial traiisrotier to 3db or suonttute additional transpclfler5 on aens berlv <br /> 15. GENERATOWSWFEROR'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 labeled/placarded,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 EPA Acknowledgment of Concent <br /> I cer ily that the waste mininhizatkxh statement Identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> s PrintedfTyped Name nor re . Month <br /> th ay ear <br /> V <br /> 16.International Shipments <br /> I— Import to U.S. El Export from U.S. Port of entrylexiL <br /> z Transporter signature for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgmerrt of Receipt of Materials <br /> 1 Pdnted/iyped Name S Month Day Year <br /> 00 .-V AL is <br /> Z Transporter 2 PrintedlTyped Name Signature y ear <br /> r <br /> 18.Discrepancy <br /> 18a.Disaepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate FaicA4(or Generator) U.S.EPA ID Number <br /> 5 <br /> Q <br /> �+- <br /> Facility's Phone: <br /> 18c.Signature of Atemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. r <br /> 4. <br /> L <br /> 20.Designated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prkhled/Typed Name Signatu Month Day Year <br /> EPA Form 8700-22(Rev. 5) Previous editions are obsolete. DESIG D FACILITY TO DESTINATION STATE(IF REQUIRED) <br />