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'r <br /> Rlease printor 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 C.A L 0 0 0 d 0 7 0 3 0 1 1 1 510-562-6989 1 024548715 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Att Tom Rabtns <br /> United#,5447-;. , United#0447.,' <br /> 4130;Go ver..Street 9469.E'Hamrr�r:W � <br /> Long Reach:GA.,90808 ,. :Stockton CA 95210 <br /> Generator's Phone: _ <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Elayviewr Industrial.Services, Inc CAL 0 0 0 -4 5 9 4 0 $ . <br /> 7.Transpbrter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility.Name and Site Address U.S.EPA ID Number <br /> US;Ecology Nevada <br /> Highway,95 11 South of Beatty <br /> Beatty 'NV $9003 -, <br /> Facility's Phone' - - - - N V` ''; <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> UN '325 1NASTE Flarre able.solids prgarnc nos I 52 <br /> 1' i DOOT,; D018 3 <br /> PGII <br /> any 50 .. P , <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> =.'8)Debris impacted rAh gasoline:Profile#070396587-0:-(1 X.55gal=).ERG#133 SIS#.22800411.2317:1:3:.;.; <br /> R©-# 21T1Z <br /> 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Jc,klell-e <br /> Signature Month Day Year <br /> Avwl �' 1 3 12.24. <br /> 16.International Shipments <br /> i= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> TranspNorter 1 Printed/Typed lCk• me Y>:( -: ' Signature Month Day Year <br /> '0 O' 322• <br /> Z Transporter 2 P ed/Ty�ped Name Jr Signature Month Day Year <br /> 10 le 2 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Yea <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 12. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month- Day Year <br /> a4-4j at,A[-e ---t YA�- <br /> (uJ l <br /> EPA Form 8700-22(Rev.12-17) Previous edit ns are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYST M <br />