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{Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2060.0039 <br /> UfFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3 Emergerf�y Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CAL00032623B 20�S yG-�1/ ► 003567535 JJ K <br /> 5,Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Pro-Active Northam Cor4einer <br /> 4343 East Fremont St. <br /> Stocldon,CA 95215 <br /> Generators Phone: ?M64 II 11 <br /> 6.Transporter 1 Company Name Us.EPA ID Number <br /> Cal'rfomia EnNronmentel 8 Litho CAROM9910 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Aebul Ernironmantal 6ervices M0202770368.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Siemens Water TechnologiesCom.Co <br /> 5375 S. alk <br /> LosAngellees,CA 0058 CAD097030993 <br /> Facility's Phone: 373-977-1 SM <br /> ga, 9b.U.S,DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group if any)) 13.Waste Codes <br /> No. Type Quantity WLNoI. <br /> 1. <br /> o Non RCRA a mrdo waste, liquid(eesl4'W G 1 <br /> ( LtJCv].rO ��ut Sac �t r ru.� 00 2. �� /10 <br /> W <br /> w r None <br /> ao � fin-► 5' G 13y <br /> C w S oLu7z e� -- - <br /> za4 ov DPI 3v G <br /> 14.Special Han ing Instm 'ons an Additional intif4limnallon <br /> Site it :5gGLtTIp✓l� OIL/ jojk� ERW7 <br /> 0-1 4114fl-IgAl.� 0( S6 rttq <br /> O[ -Z 6 CO <br /> 15,. GENERATOR'S/OFFEROR'S CERTIFICATI hereby declare that the contents of this consignment are fully and accurately described above by the proper Wipping name,and are classified,packs ed, <br /> marked and labeled/placarded,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 Pahl that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Ue r is Print dfr ped Name Signatu Month Day Year <br /> 0 , I LLf- d Z� <br /> 16,International Shlpmems <br /> z El import to U.S. ❑Expo am 11 Pod of entry/exit: <br /> Transporter signature(for exports only): Date leaving D.SI <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 7.P.r6tl�l/�[yped Name Signa Month <br /> ad YatN F18rvuY Day Year <br /> a <br /> QTransporter 2 PdntedRyped Name Signature Month Day Year <br /> C <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ <br /> Residue ❑Partial Rejection ❑Full Rejection <br /> Manife <br /> 18b,Alternate Facility(or Generator) at Reference Number. U.S.EPA ID Number <br /> J <br /> ;J <br /> a Facility's Phone, <br /> y 18e.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2' 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as aped in Item Ise <br /> Printedfryped Name Signature Month Day Year <br /> 'A Form 8700-22(Rev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) ' <br />