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0 • <br /> Please print or type. Form designed for use on eLe(12-pitch "writer.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.EmergencyResponse Phore d.Manifest hacking Number j <br /> WASTE MANIFEST CAL000269375 1 866-909-2783 008025694 JJ K <br /> S.Generator's Name and M"IAddress Goreratoes SkeAddress(dd-nwtm$nmmngadd'ess) <br /> Rick A Puli -�StocFctoss 3927 Clark Drive Attn: Doug Grose <br /> 3927 Clark Drive stockton, CA 95205 <br /> Stockton, CA 95205 <br /> Generator's Phone: 41A 74e1--4485 <br /> S.Transporter 1 Company Name U.B.EPA ID Number <br /> Worldwide Recovery Systems, Inc- =000175422 <br /> 7.Tmmpolkr 2 Company Name U.S.EPAID Number <br /> B.Oeslpnoted Fadlty Name end Sge Address U.S.EPA ID Number <br /> IIS Ecology (Beatty, H9) <br /> Highway 95, iimi- S_ of Beatty, P-D- Bow 578 <br /> Beatty, H9 89003 <br /> Fadllys Plane: <br /> 800-239-3943 HVTs300i00o0 <br /> 9b.U.S.DOT Dwcdplien(Inceding Proper Shipping Name,Hamar!Class,ID Number, !No. <br /> hem 11.Total 12.Unit 13.Waste Codes <br /> KMand Packirg GraplNany)) Type OuaMiy WlNol. <br /> Absorbent, Debris) <br /> K <br /> w 2. <br /> _. . <br /> 3 <br /> 4. <br /> 14.Special flarMlIng Instructions andAdtaleral efoimallon <br /> 1) 07-012-8300-3305 <br /> bill to Worldwide; Wear Appropiate Protective Clothing; <br /> Wk ORDER $ 219206 <br /> 75. GENERATOR'S/OFFFROR'S CERTIFICATION:thereby declare that the contents of heconalgmaM are fuAy and accurately described above by the proper shipping name,Ware classified,packaged, <br /> marked and labeledlplacarded,and ore in all respects a co <br /> PMIAT ndition for transport according to applicable haemalamal and nalbnal 90"rewntal regulations.if export shipment and am the Primary <br /> Exporter,I cemdy that the contents of Us consignment conform to the temu of the attached EPAAdenowletlymnl of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(6l am a large quamiy generator)or(b)isI am a smell quantity generator)Is true. Aonth Day Year <br /> Generate slOfferes PrNfedlfype!Name Sgnamre <br /> j .116.IMemalmne SNP"lits ❑Impede U.S. ❑Exponfrem U.S. Port of entylexk: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> i K 17.hanspoduAckroMedgmentof RecWofM , Mmih Day Year <br /> Trans er i yped Nam <br /> a yp Monza Day Year <br /> Trenspoder2 Pdned/fyped Name Sigmlure <br /> i18.Discrepancy <br /> 16a.Discrepancy Vocation Space ❑ Quantity ❑Type ❑Residue ❑PaNel ReNdion ❑Full Reach. <br /> Margeet Refermrte Numbar: <br /> U.S.EPA ID Number <br /> 186.Alternate Fedlby(or Ganeator) <br /> J <br /> U <br /> LL Fadity's Phone: Month Day Year <br /> w iec.Sgnalure of Attenuate Fadllty(or Generator) <br /> m 19.Hazardous Waste Report Management Method Codes 0e.,codes for hazardous waste treatment,deposal,and recyeM1ng systems) <br /> 3. 4 <br /> 20.Designated Facility Ownerm Operator:CerBaron of receipt ofhazanfeus materials covered by be manifest except as rated In Item 18a—I T U pay Year <br /> Pdntedlfyped Name �_. 81151t <br /> EPA Form 8700-22(Rev.3.05) Previ-ousedigonsamob ite. DESIGNATED FA ILITYTO DESTINATION STATE(IF REQUIRED) <br /> I , <br />