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Please print or type.(Form designed for use on elite(12-pito pewriter.) 0 Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> (&3V72 <br /> HAZARDOUS 1 20g-45D-0450 01 4 3 5 2 6 7 JJ K <br /> MANIFEST CALW035687r' <br /> s Name and Mailing Address Generators Site Address(if different than mailing address) <br /> FIC SOUTHWEST IRRIGATION <br /> KON.S. CAN5215CIVECKTON,CA 96215GPhone: 209- USEPA ID Number <br /> er 1 Company Namege W. Ldrrty.Inc. 2015 GAROOC947019 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> a.De nate! Facility Nam and Site Address )1��Ti�r.rpagrfier_Ar� m a <br /> �2056Y&OV�RTON INC. <br /> 1610 W 17111 Street <br /> LONG BEACH.CA 90613 <br /> Facility's Phone: 890-827-6729 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No. Type QuantlTy WLNol. <br /> HM and Packing Group(if any)) <br /> X 1. UN 1133 WASTE FLAMMABLE LIQUID It. o. s. (Adheslres) 3 PG11 I OM /0 <br /> G 281 1 Di t <br /> (owl) <br /> I <br /> (7 <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Informatlon <br /> ERG#128 TetrahydrdfUM &Methyl Ethyl Ketone PVC pipe glue INVOICE# (! <br /> USE GLOVES PROFILE# �5 37 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name,and are classified,packaged, <br /> marked and la reledlplacarded,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 codify 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 generator)is true. Month Day Year <br /> Generators/Offerors PrinledQyped Name c Signature <br /> K Z <br /> 16.IntemaUonal Shipments <br /> f— ❑Import to U.S. ❑Export from U.S. Pod ofving U.S. <br /> Z Transporter signature(for exports only): Date leaving U. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 rime yped Name Signature Month Day Year <br /> O <br /> pe Its <br /> 6 <br /> z Transporter 2 Printed yped Name Signature Month Day Year <br /> Q <br /> K <br /> r <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 /> U <br /> LL Facilily"s Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> 4 <br /> Z <br /> 22 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 <br /> Pnnte irryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />