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•ot W".aAscum. <br />Please or' t a tune. (Porro designed for use on elite (12-oitdil tvbewriteuDi=: i f2i�d.u77>n7d._ftb9 Wit-' PPiJU 3!i ii?r1-i <br />EPA Form 8700-22 (Rev. 3005) Previous editions are obsolete. 0 DESIGICATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Plane <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />011848922 FLE <br />Ir� <br />� <br />5. Generators Name and Mailing Address neratcet Site Address (li'different than mailing address) <br />Mos1tt2-in H wse Water Treatment P13t1t <br />1Q045 Kelso Road MAZE <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Cie -an Herbars ,, Inc. y .1, <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 / BAKERSFIELD TRANSFER <br />iG20 E. BRUNDAGE LANE C A L G O v 2 3 2 5 S 3 <br />Id. CA 53307 <br />ga <br />9b. U.S. DOT Description udfiig roperaping Name, Hazard Class, ID Number, <br />10. CkrntaUrers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Ncidng Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. <br />NON RCRA HAZARDOUS WASTE- LIQUIDS. DESL, WATER! <br />oCi <br />242 <br />4a <br />Z <br />2. <br />LJ <br />3. <br />4. <br />114.5$eaal 3 nd� g IO 2 Additional Information <br />52.1 W I�tot�5a I <br />Cant. act ratalned brk oenettor coflt_rs agency authority on Initial transeorter to add or substitute additional trangpotterg oil cenp-nalf <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and ata classified, packaged, <br />marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulatlons. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this coxsignment conform to the terms of the attached EPAAdu*Wedgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (q) (if I am a small quantity generator) is true. <br />s yped Nam Q na ra •Monthear <br />V <br />F <br />16. IntemaWnal Shipments <br />Import to U.S. ❑ Export from U.S. Port of entrylexit <br />Transporter signature fox exports on : Date leaMng U.S.: <br />1% <br />17. Transporter Adknowledgmed of Receipt of Materials <br />Tra m-porter1 PPrinte`diTTyped Name on ay Year <br />a <br />w,9- Y W, es G,b <br />CO)Transporter <br />2 PrintedTyped Name Signature Mc thy ear <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />Q <br />�+- <br />Facility's Phare: <br />18c. Signature of Alternate Facility (ox Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3. <br />4. <br />i. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pnintedrryped Name Sigrrahi Month Day Year <br />7" 1 <br />EPA Form 8700-22 (Rev. 3005) Previous editions are obsolete. 0 DESIGICATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />