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i <br /> Please print or type. Form Approved.OMB No.2050.0039 i <br /> UNIFORM HAZARDOUS JW-Ta t ID m 2.Page 1 f 3.Emergency Response Phone 4.Manlfelt TracId Number <br /> WASTE MANIFEST t � 6 0 4 1 4 8 7 2 1 (COQ) �4-930Q 01'2' 7 2978 FLE <br /> ' Slaoerahsafs 4ye acrd Mdibn noduCt f, LLC rtss(if different than mailfig address) <br /> P.O. Box 80249 86 9 LOUISE AVtM <br /> Rancho?Santa Margarita, CA 9if�8 o-azoo LATHROP, CA 98330 <br /> Generator's Phone: - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> BBLSHIAB „ CARD 0 018 3 9 13 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Fadli Psiteri rens US.St. EPA ID Number <br /> A Nu 0 8 0 013 3 2 <br /> h0jnated <br /> aapton,� <br /> (g10) �97-71Q0 <br /> Facility's Phone: <br /> ga. 9b.U.3KT Description(Indu6gi Proper Mpping Name,Hazard Class,ID Number, 10.Containers 11.Total- 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No Type Ouentily, W1Nol. <br /> 1. • O »r r Q 194 <br /> Q� x > 3 6d <br /> pC i <br /> Z 2. 1 <br /> W <br /> 3. <br /> i <br /> i <br /> 4. <br /> 40°r.. <br /> hN <br /> i <br /> 1 alHaDdlinglnsWcbonsandAdditionallntortnation BESI : .B <br /> 998 <br /> Caltroline S Water rA011'ZtTIVL CL 5P CCN: 203883 <br /> i <br /> 1 <br /> 45 15P 30 vp <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully an.4 accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable interdiltional and national governmental regulations.0 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a I q tity generator)is We. <br /> Grneraleslmroes Printed/Typed Nae Signature Month Day Year <br /> LarrT Noothart of�!LM an behalf of gweraeor oci r� <br /> _j 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> F-- Transporter 1 Printedayerne Signature Month Day Year <br /> Ix <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year ; <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Ou ❑T ❑Full Rejection <br /> entity ype ❑Residue ❑Partial Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> C> <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Genese ) Month Day Year <br /> Q <br /> Z <br /> 19.H ' rdous Waste Report Management Method Codes(i.e.,codes for hatardous waste(reatment,disposal,and recycling systems) <br /> 1. 2. 3. T- <br /> 20. <br /> Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> L 1 0 '�� {�S plc° <br /> EPA Form 8700-22(Rev.12-17) Previous edlBons are obsolete. TRANSPORTER COPY <br />