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Please print or .(Form designed for use on elite(12-pitch) pewriter) Form Approved.OMB No.2050-003 . TUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man"Tr"-King Number--- WASTE MANIFEST C A D 9 B 16 B a a >i t; I 577-57`7-�2G 0 0 5 8 0 9 0 4 6 JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) PACI ISI C GAS & ZiiI.:l?G'I`R C CID- MC.I OW." O :I SIANDP-0- Im 106 CRIAT. Cox►?_ FI(wf' cl, 95234 Generators Phone: 20:1 944^.L 41.3 6.Transporter 1 Company Name U.S.EPA ID Number PAILIP WEST I:1SMSIRIAL. SPRVICES C A R 0 0 0 j 1 7 5 2 _7 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Cj-MICAL WASTE YANAGEM trT. INC- ?r251011) SKYIiNE, iMD IFl1APMAN CITYCA [ }2.-'}q . A 1:11 () 0 0 If-5 4 6 i _i 7 Facili sPhone: WO 2-29V ga. 9b.U.S:DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 13.Waste Codes 1. W-RCRA H=RI7CUS WA IT, 1=113"1) AO�t--170 U o ,, rO:l I,3 S 5c�� D�br.:� �% j a�i�SG1 0 0 _,. C VA z 2. W --- 3. 4. 14.Special Handling Instructions and Add"onal Information giir -F1;1 7kt0 .:.. r,, WTI,, AND DEBRIS, i✓/D%ese f � R,I Muse S,edl U 9d &A0e 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certffy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dI am a wall quantity generator)is true. Generates/ is Prf yped Name Signature Month Day Year -1 16.Intemational Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 P- edlTyped N Signature Month Day Year QTransporte(2 Printedrryped Name Signature Month Day Year N I 18.Discrepancy 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V L Facilitys Phone: LU 16c.Signature ofAftemate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)