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Please l5dritvor type,{Form designed for use on Oils(12-pitch)typewriter.) Form Approved.OMB No,2050.0039 ar e t of 3.Emergency Response Phone 4ManifesstTrracckingi Number FUNIFWASTE MANIFEST P669-977•62$ 003332 5 65 U p 9RM iAZARbdll5I'CAU0100269375 cnerator's Name and Mallin Addleas Generator's Sire Address(U different than mailing eddress) PirK-N-�►u�.i. C►- CLARK DRIVE '-SibCKTON. CA 952054=1 Generators Phone: 2IM11-462-1927 6.Transporter 1 Company Name CRI Rscyding Spica Inc � 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and SileAddress U.S.EPA Q Number r CRI Reovefinp 5enrige Irlo Vplq, WI W28 SI 14 Paujs' harm° ga - 9b.U:S:GOT Description(Inclurtgng Propef Shi§ortg Name,Hazard Class,ID Numbef, 1 10,Containers 11.Total 12.Unit 13,Waste Godes I4M and Packing Group(dany)) No. Type Quantity M.Not, 1. 23 Ort-RCRA Hazardous Waste Solid � D P 2 W 3, 4. 14.Special Handling Instructions andAddhional Information to ani I"Y - ,fd.('r' :'i ,:.. �r P�teatlwap Ctin�1'ris! eW as. �.S C.D#[,Y ABS��tP� 171 TF GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of This consignment are Sully and accunVely desc4bed above by the proper shipping name,and are dammed,packaged, moticed and labelod/placarded,i4 are N all respeols in proper rAndillon for transport according to applicable Wemational and national governmental regulations.if export shipment and I am(he Primary Exparter,i certify that the rnntenta of lois consignment conform to the terms of the ahaohed EPApcknowledgment of Consent. I,dKUfy that the waste minimizaton statement identified in 40 CFR 262.27(3)(f I am a large quantity Senarator)or(b)(if I am a small quantky generator)Is true. Gane rslORerors P(riledfryped Name Sign t ri Morn Day Year t \ 6,InOmIrodal Shipments r ❑Import fo U.S. ❑Export from U.S. Port o1 entrylexil: Transpo4gr signature(For exports only): Date leaving U.S.: 17. ria er Acknowledgment of Reoelpl of Materials �.'Ittanswiflar tt Prime Name SigrTlu Month Day Year ransporter2 PfiniBdfTjpad Name SlIfnature an)h Day Year Cr Ia,Disvepency 183.Discrepancy Indiolion'P&" Quantity ❑T ❑Residue ❑ ❑ Type Pagiel Rejection Full Rejection Maniteat Reference Number: 1t b,Ai6emate Facklty(or Generator) U.S.EPA 10 Number U Facihr/s Phone: 18c.Signature ofAllernate Fachty(cc Generator) Month Day Year Q z 19.Hazardous Waste Report Msnagemenl Method Codas(Le,copes for hazardous waste treatment,disposal,and recycling systems) 4. H439 20,Designated Fatality Owneror Op4rstor.Cegftsilon or receipt of NazarrclDw matertafs WWOO by the mBnirest except as noted in Vern 18a PORWITyped Name 5 gnelure Month Day Year EPA Fon 8700-22(Rev.M5) Previous editions are obsolete, 9 'd 9 6�a '"N DESIGNATED FACILITY T4 GM d Z Z :Z[R g o o� 'd a SJIF I9D)