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j <br /> f <br /> j Order :434587 <br />{ Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> p UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000040030 800-633-8253 Q Q b 1 DAT <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Uhy of Tracy Wastewater Laboratory <br /> l 3900 Hotly Dr AT ftl:CaubrlQl Uucng <br /> I <br /> !,'A Wi3041616 i Generators Phone: TOO <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number <br /> Ingenlum Sacramento('-'ERI 8766-0004—) C_AR000179747 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Ingenlum Santa Clara('"'ERI 8766-00U2"') CAR000 t 79T47 <br /> 8 Designated Facility Name and Site Address --` -'- --- -- - - - - U.S:EPA ID Number <br />{ I,.,!-.:,t,,Uy Iw:,:r,�.�,Ir�c N�iT3;30010�:0U <br />` t My 95. 12 miles Soulh of Beatty <br /> NV 1:190W <br /> i Facility's Phone: ft)-2344943 <br /> i ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wtivoi. 13.Waste Codes <br /> i 1. <br /> O I,hn-R?C..RA Hazardous Waste Liquid(Citric Acid,Mamutul) bb1 <br /> ( � <br /> t` <br /> I � <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 01:(0/01316/0-26846)NI FRI FE WAI ER TES-1 VIALS <br /> G3ntract rotofned by gahereror corism sgwtcy outhorrty on ininA transporter to add <br /> a <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: 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 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(rue— <br /> Generators/Offerors Printed/Type, Name Signature ( Month Day Year <br /> 16.International Shipments <br /> �. ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W17.TransporterAcknowledgment of Receipt of Materials <br /> W Transporter 1 Printedff ed Na e <br /> w p _ Signature Month Da Ye <br /> Z Tr6nsporter2 Printed/Iyped Name Signature Month Day Year <br /> 9 >>' - 1 �y z <br /> 18.Discrepancy r . <br /> 18a.Discrepancy Indication Space ❑ ❑Full Rejection <br /> ❑ Quantity ❑Type El Residue Partial Refection' <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> L Facilib/s Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z —Tco 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. 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 /> Pnnted/T NaCCrp,e Signature f_ <br /> Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> r <br />