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s INIPW <br /> i <br /> Please print or type.(Fort designed for use on elite(12-pitch)�iii Farm Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone4 Manifest Tracking Number <br /> WASTE MANIFEST � $;1+- <br /> 85607 10002 ,52917 J J K <br /> 5.Generators Name and Mailing Address Generalities Site Address(if different than mailing address) <br /> Unrifled Western Cat=ers y U W-G <br /> A#tn: Pat Gulillermety,5200 Shelia Street 1990 Piccoll Rd. <br /> Ct?wierce CA 90040 Stockton CA 85215 <br /> Generator's Phone: <br /> 6.Transporter 1 Company a U.S.EPA ID Number <br /> Haz Mat Trans. Inc. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S_EPA ID Number J, <br /> Siemens Water Technologies Corp. Il <br /> 5375 South Boyle Ave. <br /> VT= CA 90058 <br /> Facility's one <br /> ^ 7 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group Of ary)) No. Type Quantity wt.Nol. <br /> 1 , <br /> o <br /> Non-RCRA, Hazardtcwts Waste Solid �, <br /> d (olYabsorbent) <br /> W %� 352 <br /> nm P <br /> Z 2. <br /> w - <br /> c9 <br /> 3. <br /> 4. <br /> .1 I <br /> 14.Special Handling Instructions and Additional Information <br /> 9b. 1i- diesel/oil/dirt/absorbent Profile # AP168384 r�x: <br /> -55 <br /> Gloves & Goggles <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabsiedlplacarded,and are in all respects in proper condition for transport according to applicable'international and rational governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmeni of Consent. <br /> I car*that the waste minimization statement identified in 40 CFR 262.27(a)(If I am a large quanttty generator)or(b)(If I am a small quantity generator)is true. <br /> General oY Offeror's PdntaVyW Name Signature Month Day Year <br /> 1e, <br /> 16 International Shipri <br /> I- ❑Import to U.S. ❑Export from U.S. Port of enbylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> Ix 17.Transporter Acknowledgment of Receipt of Materials <br /> Cr Transporter 1 Print yped Name Signature Month Day Year <br /> © C�- I <br /> EL .� <br /> co <br /> Te'Traps iter 2 P tedffyped Name Signatur cnfh Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number- <br /> 1 8b. <br /> umber-18b.Atemate Facility(or Generator} U.S.EPP IDNumber i <br /> J <br /> U <br /> LL Facility's Phone: <br /> O - Monkh Day Year 11 <br /> ry <br /> 18c Signature of Alternate Facility(or Generator) <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1. �� 2. 3. 4. <br /> t <br /> I <br /> 20.Designated Facility(honer or Operator.Certification of race' t of hazardous m dols covered by the manifest except as note n It 1 Be p <br /> Printedffyped Name Signature Month Day Year <br /> it/tA r V-,' <br /> i i <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete: DESIGNATED FACILITY TO GENERAT R <br />