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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTEMANIFEST '-"I;'•a'•Cva7? 7 ::B-•i^C�-0.€�,Lt 013435261 JJK <br /> Ger feraIto(s�Namg ai�d Mk1ailin�Add,�ese, Generator's Site Address(if different than mailing address) <br /> _{'�R41FiG :Sl?UTIi'v`r v.S. lhRIGRTtdJ ® <br /> ta79 5. JACF7LINI RLI. ry 1` ' <br /> uSTOCKTON,CA '95;:15 1v= V <br /> Generators Phone: X'4+4ffj)""�V <br /> B.Transporter l Company Name U.S.EPA ID Number <br /> George W. L0art4.file. <br /> 7.Transporter 2 Company Name ^� U.S.EPA ID Number <br /> B.Dagjgnated¢polily,NemEapQSiteAddress rj r1:D9 H U.S.EPA ID Number <br /> .,.1611=k 1i1G ;s[r0et <br /> Facilitys Phone: <br /> CKOJ V-SS.7.9 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conlaineor 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wilvol. <br /> 9 1. tlid I!-;-.',kt:\uTL FL-',k%f18LE.LQ ID Cl.. ::. 6. (P..0iie5kw' 3 Pati <br /> � i7C&3tj �C <br /> Q0 <br /> K <br /> 2 Z. <br /> W <br /> V <br /> 3. <br /> 4. <br /> .S ecial Handling lnstiuclionsand Additional Information <br /> �'FC3W 1.'di" Ta1y,SrfyL'C%,IUT u r4a,h f F thvr KStu1w daVC Pepe JIUE / <br /> ll=i'.:[iII.T'JEj 1;Wr?f'(LL`?r <br /> 1p; !I <br /> 15. GENERATOR'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 Iabeledlplacarded,and are In all respects In proper condition for transport according to applicable international and national governmental regulators.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 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 genejater)is true. <br /> GeneratofsfOfferyrs Printedityped Name r, - SlgnaNre :- z^�` MoF�' Dag Year <br /> e'r k fT.a;E-�'n6r :' T,•r�', .! a4 �C( /sem <br /> .� 16.International Shipments <br /> p_ ❑Import to U.S. ❑Export from U.S. Port of entrylezif: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Signature <br /> I' Mon Day Year <br /> Transporter nntedlyTyped Nargi!J {F g �•' et tcp" <br /> O f Ln, ;,i� f ,i._. ,, ! <br /> z Transporter 2 Pdntedffyped Name Signature Month Day Year <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity - [--]Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.51gnalureofAltemate Facility(or Generator) Month Day Year <br /> a <br /> .Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O ' <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of mmiptnfhazardous materials covered by the manifest except as noted in Item 1B <br /> Pnntedflyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />