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Please print or type. (Form desioad for use on elite (12-uitchl•lwewflter) <br />Form Arnrrnmd. nMR No. 2W".1A <br />LVA Form 8700-22 (Rev. 3-05) PreAous, edition are obsolete. DESIGINIATQP. FACILITV To 0 DEESTIRATION STAYE (IF REQUIPED) <br />UNIFORM HAZARDOUS 1. Generator ID Number I Pago 1 a Emergency Response Phone <br />ManifestTrackIngNumbeir <br />WASTE MANIFEST C AC 0 0 2 6 8 0 0 65 1 � i rl"IRCES 51&749-130a <br />— <br />007210682 JJX <br />5. (Jenerato(s Name and Mali Address AT SURIN DERKCHUMBBERenwalces Site Adressddifferent than mailin ddrass)INIFIN[TYTRAN, ORTAT(ON IofC. INFINIff -PaRTAqW <br />I Rj C. <br />iQ GOLDSTONE CIRCI P 500 E ROTH RD <br />SACRAMENTO •CA 93834 LATHROP CA 95048' (vmvp- eow <br />Generator's Phone: 9 1 a 4 3 9 6 3 <br />S. Transporter I Company Nam* U.S. EPA ID Number <br />1 -IRC ENVIRONVitENTAL SERVICES INC. C AR 0 00030114 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Desirated Facility Name and Site Address U.S, EPA ID Number <br />.rosby X Overm, I rr.. <br />1820 Xtkk 17th Street <br />LongBnoh CA 90813 <br />Facility'siphona: 502 4,32-5445 C A D 0 2 8 4 0 9 0 1 9 <br />ga. <br />9b. U.S. DOT Description (including Roper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />111. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />M <br />and Pecking Group of rmy)) <br />Quantity <br />wrivol, <br />1. MON-RCPA HAZARDOLISWASTE SOLID (SOIL W-114 DIESEL <br />AND HYDROCARBONS) <br />kit <br />3. <br />4. <br />14.Sp�tairHandgnqlnstrudiomaMAddiffenalinfomatiozi <br />54 21 OPER. <br />g PERSONAL PROTEC-MM EQTJILw1lZNT <br />JOB/POtz-553.21 PROFILE :gS7426. <br />14-W ENVIROIStMI-PAY, 3URVICES, 1605 E'ER.? POINT, AWEDA, CA 94502 <br />115. GENERAT0R'S10FFER0!KS CERTIFICATION: I hereby declare that the contents of Ibis consignment are fully andaocuia teydescribed above by the proper shipping name, art are classified, packaged, <br />marked and ebeled/placallidled, and are In all respects In proper condition for transport according to applicable International and national governmental regulations. It export shipment and I am the Primary <br />Exporter, I certify that the contents ol f this consignment conform to the terms of the attached EPAAcknowledgmantof Consent. <br />I certify that the waste millimizatiDn illialement identified in 40 GFR 262.27(a) (I I am a large quantity generator} or (if I am a small quantity generator) Is true. <br />Ganarator'sfDKerorsPrint"T Nam Stgnaiura Month Day YAW <br />Internallomll Shipments ❑ Import to U.S. U Export from U.S. Port of entrylext: <br />Transporter signature ((or expo ft� only): Date leaving U.S.� <br />Uj17. <br />TransporterAcknoivedgment of Receipt of Materials <br />�j <br />Trari!p&r I Pdrited/Tyineq Name J Sig Month Day Year <br />0 <br />1 <br />Transporter 2 Indotimrypeti Nam Sig Month Day Year <br />19. Discrepancy <br />18a.0, screplancy Irdcation Spacertial Rejection Full Rejection <br />El QuantityQuantity13TYP. ❑ Residue ❑ Pa <br />Manifest Reference Number <br />18b. Alternate Facility lot Generator) U.S, EPA ID Number <br />CY <br />aA- <br />Fadilly'sPhons: <br />cu] <br />185 Signature of Alternate Facilly (or Generator) <br />MonthDayYear <br />55 <br />iu.Hazardous Waste Report Management Method Codes 0,e., codes for hazardous waste treatment disposal, ardl reqdIP4 systems) <br />LAJ <br />20 Designated Facility Owner or Operator. Certification of recalp(of hazardous materials covered by the manifest except as noted In Rem 118a <br />Pnn ed Normo Signature Month Day Year <br />LVA Form 8700-22 (Rev. 3-05) PreAous, edition are obsolete. DESIGINIATQP. FACILITV To 0 DEESTIRATION STAYE (IF REQUIPED) <br />