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Please print or ype (Form designed for use on elite (12-pitch)1y *wilt r.) <br />FamA aved. OMS No. 2050.0039 <br />EPA Form a700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENEROOR <br />UNIFORM HAZARDOUS <br />1 Genafatof ID Number <br />2 Page 1 of <br />3 Emergency Response Phone <br />4. M TR c1d P) <br />WASTE MANIFEST <br />CALOW329569 <br />In <br />b T812 2 2 JJ K <br />5 Generators Name and Mallirg Address Generators Slte Address (d diftrant than mailing address) <br />3ird Road Yard & Shop Facility <br />)3623 S Bard Rd,Tracy, CA 95304 ���:�� © <br />Generators Phone: 510-715-8466 <br />6 "ransporter 1 Company Name <br />NOV 17 2017 <br />U.S EPA ID Number <br />AC (4ASTE OIL <br />7 TrarrsporW2Company Name <br />SHIMMICK CONSTRUCTION <br />U.S. EPA <br />Systems <br />EQUIPMENT DIVISION <br />8 Designated Fadity Name and SM Address — _ U.S EPA ID Number <br />n= Environmental Services, Inc, <br />?730 East 13th Street Yuma Arizona 86365 <br />Facility's Phone: ke , <br />9a. <br />9b U.S. DOT Desafption (mdudmg Proper Shippirg Name. Hazard Class, ID Number, <br />10. Contatrxre <br />11 Total <br />12 Unit <br />y 13 Waste Codes <br />No <br />Type <br />HM <br />acid Paddrg Group (d any)) <br />Quantity <br />WUVOI. <br />1 <br />NON -RMA iiAZARDOUS WASTE SOLIDS <br />9 OILY 0 <br />UJI <br />3, <br />4. <br />14 Special Handling Instructions and Add*Ml I nation r <br />15. GENERATOWSIOFFERORS CERTIFICAT*N: I hereby dedare that the contents of this consignment are hilly and aauratety desafbed above by the proper shipping name and ereclassified packaged <br />marked and labetedlptararded, and aro In all respects in proper condition for transport according to applicable international and national governmental regulations If export d*wt end I am the Primary <br />Exporter l certify that the contents of this conslgnment conform to the terns of the attached EPAAdmoxledgmenl of Consent <br />I cortity that the waste rnhirtdzation statement Identified in 40 CFR 262-27(a) (if 1 am a large quantity generator) or (b) (d I eni"a small quantty generator) is true <br />Generatarsfl %mes NntedNyped Nana 519 ture Month Day Year <br />J <br />16. International Shipments ❑ P� ❑ Export from U.S. Port of e <br />Irn to U.S. nti+/�wk-------- - <br />Transporter signature (for exports Orly): Date leavrg U.S <br />17. Transspo r Aclawoodgment of Reeeipl of Materials <br />Transporter + ?amad typed Name Signature l�Ih Day Yaw <br />cc <br />o <br />� <br />_ = Z <br />:Name <br />Z-, <br />ranspomr 2 P -iMac. Spr MorM Day Year <br />a <br />!ti Z 1-7 <br />18. Discrepancy <br />i6a. Discrepancy Indication Space ❑ ❑ Type ❑ Residue ❑Portal Re)eCion ❑ FuA Re}edim <br />Manifest Reference Number. <br />18b. Altemate Fedlity (or Generator) U.S EPA ID Number <br />U <br />Facilitys Phone: <br />Lu <br />18c. Signature of Memate Fadity (or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Manarment Method Codes (Le, codes for hazardous waste treatment, disposal, and recyckV systems) <br />G <br />20. Des{ natal Fadtity Owner orOperator Cvitfiration of receipt of hazardous materials covered by the manifest except as rated In Rem Me <br />n" typed Nim monf, ay i <br />' J \e ! r Q 1 <br />EPA Form a700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENEROOR <br />