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Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3:Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I CAR000220046 1 909-984-9984 016408878 F <br /> 5.Generator's Name and Mailing Address Generator's SileAddress(if differentthan mailing address) <br /> CALIFORNIA HEALTH CARE FACILITY (07557) 7707 SOUTH AUSTIN ROAD <br /> 7707 SOUTH AUSTIN ROAD (attn: Anthony STOCKTON, CA 95215 (attn:Anthony Vanni) <br /> STOCKTON, CA 95215 <br /> Generator's Phone: 209 467-7904 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> INDUSTRIAL PTASTE UTILIZATION INC. CAD980585293 <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 /> PACIFIC RESOURCE RECOVERY <br /> 3150 E. FICO BLVD. <br /> LOS ANGELES, CA 90023 <br /> Facility's Phone; 800-499-7145 CAD008252405 <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,HazaM Class,ID Number, 10.Centel TS 11.Total 1 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLNol. <br /> 1, UN1325, Waste Flammable solids, organic, n.o.s. D001 352 <br /> p (xylene/thinners) , 4.1, PGII ---, - <br /> nm 5 <br /> z 2. <br /> W <br /> u' <br /> 3. <br /> 4. <br /> I <br /> i <br /> 74—special Handling lmiructions and Additional Information �g�'g n t� <br /> 1) flammable nags-ct.l#64852/app#�LL,/ L "ERG #: 135 <br /> VT. 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 are classified,packaged, <br /> marked and Iabeledlplacarded,and are In all respects in proper condition for transportaccording to applicable intenretionaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certy that the contents of this consignment conform to the terms of the allnhed EPAAcknowledgment of Consent. <br /> I certiy that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)if I arrj#small quantity eratoq is true. <br /> Genemdor'slOReror's PdntedlTyped Name Sgnature Month Day Year <br /> 6,y 1 c5 10&1 <br /> 16.International ShipmentsEl <br /> F, Import to U.S. Export from U.S. trylexi[. <br /> i Transporter signature(for exports only): leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> out <br /> Transporter 1 Printed(Typed Name Si Mcnih DayIII <br /> Year <br /> R �f �7A R C - G�� S CS <br /> aZ Transporter2 PdntedRyped erne SgnaWre Month Day Year <br /> a' <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> iao.rowumro rwcnuy(or ooreewq US.EPA IO Number <br /> J <br /> U <br /> LL Fealty's Phone: <br /> w lee.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> c 1. 2. 3, 4. <br /> 20.Designated Facility Owner at Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> 111 Pdntedrryped Name t Signature Month Da Ye <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. D NATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />