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_ X4.4-•^' _ <br /> Please print or type.(Form designed for use an elite(12-pitch}typewriter.) Form Approved,OMB No.2050-0039 .+ i <br /> UNIFORM HAZARDOUS 1-Zrator IDNumber <br /> �^ j 2.Page 1 of 3.Emergency Phone . 4.Manliest Tracking Number j <br /> WASTE MANIFEST A� t�� * . I I 1 j�- 3.t 1. 0 0" 3 4 7 4 0 2 G B F <br /> 5.Generator's Name and Mailin Address Generator's SiteAddress d d' Brent t an mailingadd ss <br /> 11 Ft nt � 3 GrzC,C S l t.#4Fl � 2� <br /> 5aoo sAe��L A S avxr cornu eger— I C\L > Pt Ctu AJ- tom. 'Po�Qx <br /> (:)0-7S0-�5 <br /> Generator's Phone: 3 � 1:;')1 U CZ040' 1-CV2-VY\ " <br /> 6.Transporter 1 Company Name, J. U.S.EPA ID Number <br /> tz .i <br /> Sac aquin Y.11ter 1?.t.cYcftn _ f':,A,000102751 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility 'ep+ {`j } 7 /,, U.S.EPA ID Number <br /> -14287 E. f i'1#iFlin . 1L-anter- f.A. 93648 <br /> i'559)498-0240 <br /> Facility's Phone: <br /> ga 9b.US.DOT Oescription(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pacleng Group(if any)) No. Type Quantity' W1.Nol. <br /> 1. - ttazaiduas , . _ . <br /> .1 <br /> LU <br /> 3. <br /> 4. <br /> 14:'S =I Handling Instructions and Additional Information <br /> VSiear:Protecth"e C lothin ><,.t,.; ;< . -Emergency Response <br /> Contact-- San Joaquin Filter Rercyding <br /> (559) 498-0240 <br /> 15. GENERATOR'S10FFEROR'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 labeleWplacarded,and are in all respects in proper condition for transport according to applicable international and national 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 EPAAcknowledgment of onsent.' <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I'am a large quantity generator)or if I am a small quantity generator)is true. . <br /> Zneratara�s Print dFTyped Na r-- Signature,-' Month Day Year" <br /> fir-. ' <br /> -J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U. . Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LU LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prinledlfypbd Name Si Month Oxy Year° <br /> CL Q� Cvic Z- <br /> 2 Transporter 2 Pdntedrryped Name -signature Month Day Year" <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type El ResidueI <br /> - ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> lab,Altemate Facility(or Generator) U.S.EPA 10 Number <br /> Facility's Phone: <br /> LJ 18e:Signature of Alternate Facility(or Generator) Month Day Year. <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,oodes for hazardous waste treatment,disposal,and recycling systems)- <br /> WG 1. - - 2. - 3, <br /> H.i41. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintediTyped Name - Si re Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete: <br />