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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number . WASTE MANIFEST GAR000220046 909-384-9984 016409253 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) CALIFORNIA HEALTH CARE FACILITY (07557) 7707 SOUTH AUSTIN ROAD 7707 SOUTH AUSTIN ROAD (attn: Anthony V) STOCKTON, CA 95215 (attn:Anthony Vanni) STOCKTON, CA 95215 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number i Tur 7.Tra srrter 2 Company Name U.S.EPA ID Number �QE-r 8.Designated Facility Name and Site Address i U.S.EPA ID Number HERITAGE EHVIROBMENTAL SERVICES,LLC 284 E_ STOREY ROAD COOLIDGE, AS 85128 Facility's Phone: 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. UR1493, Waste Silver n1trate, 5 .1, RGII D001 D011 311 z 2. L t7 � 3. i I 4. j i 14.Special Handling Instructions and Additional Information 1) salver nitrate applicators—ctl#64846/app#221574-1; ERG #: 140 R r 15. GENERATOR'SfOFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. Generator's/Offero(s Printed/Typed Name ON E3C14A LF C)1= Signature Month Day Year .JENNIPEt2 SES P-AIJa d-il 11i8 2-1- 16.International Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials UJ t2 Transporter rinted/Typed Name Signature Month Day Year CL �1l 22 Z Tran oder 24ri nted/Typed Name Signatu Month Day Year / 11 n4 Z 18.Di crepancy 18a.Discrepancy Indication Space ❑ QuantityType❑ yp El Residue El Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V uQ. Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1 '_ ! ' 2. 3. 4. Ll20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noWd in Item 18a Printed/Typed Name uvSignature Month Day Year nXIC6AA &—I EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATEQ FACILITY TO EPA's e-MANIFEST SYSTEM