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Base print or type.(Fano dejigned for use on elite(12-pitch)Vpewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 <br /> 1_Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CALtKl03}137X4 1 O' r .�->,': " "^ 1. 'i: 0 0 4 - 93603 JJK <br /> Generator's Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> CENTRAL Si,,Lti C7 1NC <br /> 181G11012-W3WAY <br /> STOCK'TON.CA 9320d <br /> GereratorsPhone2,4-J"3-1234 <br /> 6.Transporter I Company Name U.S.EPA 10 Number <br /> FREkQLFWV ENVIRGPYNEN rA SERVICES INC rIhcarlr#80IJL559-32;4 ��AR(J0091 1101 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ist('rff1URY ENVIRICN-AAENTAt MANAGEMENT OF NEVADA s,Lr: "—1AROW164013 <br /> 8.Designated Facility Name and Site Address U.S-EPA ID Number <br /> 21ST CENTURY EN41 <br /> 20195 NEWLANDS DRIVE. EAST NVF1881:u 33A <br /> F�R¢aLEY F1V7 8b4O13 <br /> FarAiN'sPhone <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Flazard Class,ID Number, 10,Containers 11.Total 12.Unit t3.yy des <br /> HM and Packing Group(if any)) No. Type Quantity WI.NoI. <br /> 1' Non,-RCRA Hazardous VJa%e 30d(Fffter Cakes+ <br /> w <br /> z 2. <br /> LU <br /> C7 <br /> 3. <br /> 4, <br /> 14.Special Handfing InMct ons and Additional Information <br /> HANDLERS TO fir 40HR TRAINEE AND WEAR PPE <br /> ffF 1; <br /> 3t382494)0 ERG#17 1 <br /> 15. GENERATOR°SIOFFEROR'S CERTIFICATION: I hereby declaret the contents of this consignment are fully and accurately described above by the proper shyping name,and are classified,packaged, <br /> marked and labeledUplacarded,and are in A respectstion Tor transport according to applicable intemationaland national govemmerial regulations.If export shipment and I am the Primary <br /> Exporter,I cwify that ire contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent- <br /> I,cerfity 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 /> torstOfferoes Printed/Typed Name Signature , , . F- MYep <br /> .-r tti-Intemationai Shnpmenls <br /> T ❑Import to U.S. Export from U.S. Port of entrylexit <br /> Transporters ature(for exports only):>9n Po Y)- Dale leaving U.S.: <br /> 17.TransporterAcknoWedgment of Receipt of Materials <br /> LU <br /> Twaspefter 1 Printed7lyped Name S'n ure M� day <br /> 9 11 \ Year <br /> N .�` +,—"- f~). It S• E`� -- ��----�� !�� � <br /> z I ransporter 2 Pdnled/Typed Name Signahure <br /> Month Day Year <br /> h- <br /> 18.Osscrepancy <br /> 18a.Discrepancy Indication Space ❑ Quant ff�'�11 <br /> ty Type �Residue ❑Partial Rejection L�Full Rejeccileon <br /> Manifest Reference Number: <br /> H 10b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> r� <br /> u�. Facil1ys Phone: <br /> 18c.Signature ofACtemate Facility(or Generator) Month Jay Year <br /> 4 <br /> z <br /> y19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. � T <br /> 3. 4. - - <br /> i ! <br /> 20.Oesignaletl Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> PrinledlCyped Name Signature I-. -4� Month Day Year <br /> FPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO f GENERATOR <br />