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Please print-or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OM6 No.2050.0039 UNIFORM HAZARDOUS 1.ijenerator ID Number 2.Page of 3.Emergency Response Phone 4.Manifest Tracking Number �`Q p I WASTE MANIFE5T A09 � ;J � '" Q 0 0 0 0 V 1 V V 7 O Q F 5.Generatoes Name and Mailing Address Generators Site Address(if different than mailirg address) U11tIF'1 U � r �t ��t1c ui�► - G, 5eI404 SNV►LA � CbminEw_ce CAA0040 1° Generators Phone: lOC�" ` QJ -i ZI yqc 6.Transporter 1 Company Name U.S.EPA ID Number San Joaquin Filter Rec-vo3iiim . CIU.0001027 l 7.Transporter 2 Company NameU.S.EPA ID Number 8.Designated Fadi Na a and rte Add s• U.S.EPA It]Number 'ar` ler N .,rl�' 1.4297 E. Xlc"IIf,rI ng, P'rlicr, CA, .93-699 C _0001077-51 Facilitys Phone: 9a 9b.U.S.DOT Des0ptiom(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No.. Type Quantity Wt.Nol. 1. CINN RCRA Ha7xdou£ Waste. 721 z 2. Lor u' 3. 4. w cif - r 14.Special Handling Instructions and Additional Information- Wtar Protec;ti�.'w t:lntl7in Emergency Response DlL/YY11 Cue ' ConUact- S.In JoiquiP Filter RQ, ycling f559) 49S-t}2�44 E 15..GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and,acebrately described above by the proper shipping name,and are classified,packaged, € marked and Iabeledlpiacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a 1prge quantity generator)or(b)(if I am a spall quantity generator)is true. Genwa4rgoiteros Printed/Typ Name r�r Signat Month Day Year Ino - o o�. .j 16.International Shipments 1= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: 2 Transporter signature(for ex1prts only): Date leaving U.S.: I w17.TransporierAcknowledgmefit of Receipt of Materials Transporter 1 PnntedlType Name Signature Month Day Year i! CL v j Q Transporter 2,Prinlecillyped Name Signature Month Day Year a I F" 18,Discrepancy 18a.Discrepancy Indication Space El Re ❑ Quantity ❑Type ❑Residue: ❑Partial Rejection jection Manifest Reference Number: 16b.Alternate Facility{or Generator) U.S.EPA ID Number Facilitys Phone: w 18c.Signature of Alternate Facility For Generator) Month Day Year € a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1.� 2.H141 i 20.Designated Fadlity Owner or Operator.Certification of receipt of hazardous materials covered,by the manifest except as noted in Item 1 Ba PrintedlTyped Name T Signature .1�~ Month Day Year i .. lot 1 1910 ' EPA Form 87 O-22(Rev.3-05) Previous editions are obsolete. _ DESIGNATED-FACILITY T'0 GI_NV_RAMR_