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Please nrint or Noe. (Form desioned for use on elite (12 -pitch) Noewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editionsare obsolete. - DESIGNATED FACILITY TO DESTINATION STATE(IFREQUIRED) <br />UNIFORM HAZARDOUS+ 1. Generator ID Number <br />2. PaQge�1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />0 0 4901365 FLE <br />WASTE MANIFEST CAC002673069. <br />(G <br />888-785-7225 <br />5. Generators Name and Mailing Address Generators bastAddress (if different than mailing address) <br />Rabobank H.A. 635 S Aurora St <br />1407 I St Stockton, CA 95203 <br />Modesto, CA 95354 <br />Generalors Phone: . 57—RRai <br />ansporter 1 pony ante U.S. EPA ID Number <br />Advaruced Chemical Trans oxt CAR000070540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />IIS Ecology Nevada, Inc_ <br />P_0 bon 578, Hwy 95, 11 wiles S_ Beatty <br />Beatty, HV 89003 <br />Fadlilys Phone: NVT330010000 <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />Quantity <br />WtNol. <br />1. Hon RCRA Hazardous Haste, Liquid (9atexbased <br />Ink) <br />P <br />331 <br />((p <br />S kae� <br />�r * <br />0 <br />2 aeiPr� <br />3 <br />1 d G <br />4' nN (2C-P.A t+,+ZAJ200c1S uIAS' e L-1 DOI ii <br />(DLAT< p�vrI-0l`15P) <br />C) 01 <br />14: Special Handling Instructions and Atldtionalinfofmation <br />1) 07diil.570-4284; BAD-ZVI-6(1 " ;, t77o13IS'70-t40q <br />Project Number: CV92675-01 3 O'At I —y O 4 ; 412AV'02 %131 6xc.4"S� <br />15. GENERAMfrS/OFFEROR'SCERTIFICATION: Ihereby declare that the contents of this consignment are Polly and accurately described,th 'by theproper shipping nor, -and am classified, packaged, <br />marked and-Iabetedlplacankd, 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, ).certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br />1 certify that the waste minimization statement Identified in 40 CFR 26227(a) - (if ;I am a large quantity generator) ar (b) (d I am a small quantity generator) is true. <br />coeroeo sPrin - Name /gmAe Ir OF 2'4607 A W- gna re on ay ear <br />, <br />i��f r / % <br />�-. <br />16. International ShipmeNts <br />❑ [.P.A. U.S. ❑ Export from U.S. - Portof en4ylexit <br />z <br />Transporter sinature(for exp6 only): Date leave U.S.: <br />w <br />17-TanspaterACknwAedgmenl of Receipt of Materials <br />Trmspo 1 Pgnt yped No <br />Signature on ay ear <br />a <br />6 <br />i r'l d <br />?nl <br />QTransporter <br />2 Prnted[TyW Name Signature faray iear <br />K <br />F <br />18. Disaepancy <br />its. Discrepancy Indication Space ❑ Quantityyp <br />❑ T e El Residue ❑ Partial Rejection ❑Full Rejection <br />Manifest Reference Number <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />7 <br />Q <br />Q <br />r+- <br />FaciGl s Phone: <br />W <br />18c. Signature of Alternate Facifity(or Generator) Month Day Year <br />6 <br />Z <br />19. Hazardous Waste Report Management Me" Codes (i.e., codes for hazardous waste Vestment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4. <br />20. Designated Feu7ity Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18e <br />1 <br />Pdntedltyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editionsare obsolete. - DESIGNATED FACILITY TO DESTINATION STATE(IFREQUIRED) <br />