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r <br /> Please print or type.(Form designed for use on elite(12-pitdy.,EWdter.) <br /> Forth Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genemter umber 2 Page i d 3.Emergency Response Phone.... 4.Nanifeat Tnc"m NumbW <br /> WASTE MANIFEST V 0 i 6 6 0 O 0 C G p C <br /> 5.Generators Name and Mailing Address ahem s SlteAddress(i di ren Than mailing acidness) �J V s7 ll D r <br /> 18101810 P 3ROM oc <br /> Garheratoys Phos 5TOCKTON.OVAky <br /> CA 962176 <br /> 6.Tmnspater 1 n <br /> U.S.EPA ID Number <br /> 7.Trenspater 2 Company Name CAJl0001'7101) <br /> U.S.EPA D Number <br /> 8.Designated Faulty Name and Site Address <br /> _ U.S.EPA D Number <br /> 44MI R 11�Nit DMAg CADM446074 <br /> CAM,CA OM16 <br /> Facii esPhone:510-1176M00 <br /> 98, 91b.U.S.DOT De50113001p(including proper Shipping Home,Hazard Class,1D Number, 10.ConuNxars <br /> 11.TOtel ol. <br /> M am Pecldng Group It any)) No. Type Quantity VnNW[Nd. 13,Waste Codes <br /> 0 1' NiwRCRA Hltsf oro VIM**LwW 113"vftWF .,7916ra O 223 <br /> Z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handing Insbuctions and Motional Information TFT <br /> 1hN ors Ira 6,4O71F 11raNrd - <br /> 6Tto O 111 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deuam that the contents of this consignment are fully and acoumtely described above by the proper shipping name,and are classified,packaged, <br /> marked and IabeledlplacaNad,and aha 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 Certity that 1110 contents of this consignment conform to the terms of the atached EPAAduaMedgment of Consent <br /> I certify that the waste minimization statement identified n 40 CFR 262.27(a)(t I am a large quantity generator)or(b)(dI am a small quantity,generator)is true. <br /> Generata'00flerors Printedrfyped Name Sgnatae Month gDay <br /> Year <br /> J 16.International Shipments <br /> i'— ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z TmnspWK signature(ter exports ordy): Date leaving U.S.: <br /> W 17.TmnspalxAdmoydedgmentof Recept of Materials <br /> O Tran 1 Prm � V �� Sgnaha§r/ ._ .. , .. Month •. i. �h <br /> Q Transporter 2 Printed/fyped New Signature <br /> Month Day Year <br /> H <br /> 18.Dweparwy <br /> 18a.Discrepancy Indication Spare ❑ Ouentity ❑Type ❑Residue 0 PaNel Rejection ❑Fu7 Rejection <br /> Mended Reference Number: <br /> 18b.Atemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facil Ws Phom: <br /> H18c.Signature of Alienate Facility(or Generntor) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Managemm t Method Codes(i.e.,codes for hazardous waste th:abnaM disposal,and recycling systems) ' <br /> 2. 3. 4. <br /> 20.DesigutW Facility Owner a Operator Cendixab n of MOV M hezadaus materials covered by the manifest except as noted in roam 18a <br /> Printelffyped Name Signature Manor Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATORrs IWITIAL COPY <br />