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Oct. 22. 2012 1:33PM <br />UNIFORM HAZARo0U8 11• Ganamtor lO Number 2. PegetaF acme ...... p'�•eu, umo no. zuol}9u39 <br />rgelNyRoeparlgaPhone• d. n nTra� u r <br />WASTE MANIFEST A R 0 0 O 2- d 9 n 7 2 clue..�:1Ofa d 9 «� 16 JJ E( <br />S. Gerlemto(a Name end Mailing Adtlresa Oensmlor Sita Addross (dddrarem manmaifing address) <br />VICK N WJI.I. #10 <br />EXAI STOCKTON HL ui7 76f15T1, t p;T1)1 j RLVU <br />,3ACRAKNTO CA 9151123 -1ACKME:NTO i"It. 9W)Oenereaafs Phone: <br />Q 16 6. Transporter l Company Name <br />U.S.EPAI Number <br />7. Tlarmpoder2 Company Nema C +A D 0 2 8.1 7 7A 3 r, <br />U.S. to Numbey <br />B. Oeslgnaled Fealty Name and Site Addreas' <br />U.S.EPAIONmrlw .. <br />DIXa6&ON WAY <br />CA 9M <br />I'mil'swane: tTa7li�i}6Dp� !� A x Q'# o U 9,' L 16 0 1 <br />Se. 9b. UA OOT OeerII N(Induding PmperSNpplrq.*a. Rar«d Chu, 10 Numhmr 9uC <br />rs . <br />HM end eaddrg Gmup(Neiryp11.1NY CFC, 19. Weds Codas <br />1. <br />TYR � "[MY 'WUyaL <br />--4 <br />t406MORA NAZAIiMS WASTE, LIWO (ETHYLME GLYCOL <br />C T C, <br />2 <br />3. <br />d <br />14.9pedd Handling instructions onclAdmwid mwmahon <br />IIIAL'RG#A9l :171 ' F'RQFfLE i BB! ' [3KIq(}2 3 `SA R( M1ICJY GUNTACT: C,HFM117f'C 1 {T00-Aid-� 3CA'?lCJI](11nNgi; CPA <br />CO'JE'3: 081: , NONE IAPPROPRJATE PERwhk PROTECTNP EGlkPI rJT <br />15: OENERATOR'SIOFFEROR's CERTIFICATION: I hereby declare Nal the indents of IN, consignment ae,7 and ecaMET deSMW E13M by rile proper shipping now, and are da"fRed, peMed, <br />marked and labaledplacarded. and am In all respacM In popar caMNan falmnepMaaardlrg to avDllcabla Idemapmslandeational govemmanlal mgulalma, NOW empment end l ammo Primary <br />Eapatar, I certify that the mnImbe d "a condgnmemmnfo m ro the terms tuna eWed EPAA*K W Wgmmt of Consanl <br />- <br />ImNfymeltlrewameminMlzatlonNelanrenlldemMed g40CFR M.Y7(a)(N l em a largo quantity genemlw)or(b) (dlem a small quaNMy gemmtor) Is we. - <br />GenemofslOReroesPdnlad7TyyodName Slgr�aNm Month Trier <br />187amaliona15hlpmenla. ❑InwltroU.S.- -, t <br />❑Export from US, Pod**^* <br />Transporter 4lgr19N1e (for oxpoda ony); "Dupe Wft us.: <br />17. TransportorAtIm wedgmept of Roelpt of Met <br />Transporter 1 Pdntedirl eWNema Slgnsnre Mmm gay Year <br />Imnspoder 2 From Iypod mB Signature Day <br />YM <br />19. nisaepaacy - - <br />189.OievepancylndleallmSpamLlOanslRy <br />AWa ❑ ResNue ❑ P.M ReJeWm ❑ FN Re)ectlm <br />MaNfasl Ref mance Number. <br />18h, Alternate Facility (ar(ierlamt(p) UA EPAIO NN* <br />Fadlly's Phone: . - - <br />ac.SigrtalureofAllemataacifty(mr Oalamtw) - Mand ay Year <br />19. Hazonome ftsle Rgporl. Msnagem nfivamod codes (1.&, mdu Rghesardousymte beamed, disposal. and maydleg 9yekms) <br />1. 2. 3. - <br />d. - <br />29. boslgdded Fadity owwor.opftW' Ca9Bmgal o{raoNptdhazHMoue materiels revered "a mohlaet empl as ndad In Item Isa <br />nlBNfypod Nema 6gruhare Monty Day Year <br />i 1 <br />EPA Form 3700-22 (Rev. 3-M Previous ecillione <br />GENERATOR'S INITIAL COPY <br />