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DTSC. 02723 . 16 4.6 v <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) I I Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST CA.:t.,00'03°78900 Y 925 540-7511.0 010 4�3 6 8 8 JJK <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> PAC=K LT_S:° P_=_.2­CL�� I= <br /> 550 Lam_ 9ALPYCO ROAD ARZO 121=k A:2/K3 <br /> Tom, CA 95376 550 U_ wALI-3 1CO RDZID, <br /> Generators Phone: 925 548-3910 At>fn:ZDGAR R2EBRALLAB TRACY , CA 95376 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> AM-0 SERVIECE,S, ZEC. CAM00189431 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> DE_=0/K9PJ Z <br /> 2000 N_ ALA:7EDA STREET CAT080013352 <br /> CIMVY019, CA 90222 <br /> Facility's Phone: 310 537-7100 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity WuVoI, <br /> 1. <br /> 0 11011-RCP.A M&dAR11rjI1S I STE Ll UID 1 aal <br /> (WATER WITH TP.ACE HXDRMAR� IIS) <br /> w <br /> w 2. <br /> c� <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Addidonal Information <br /> AV01D M COATEICT 6 MAR RUBBUR GLOITZS ERG 1.28 <br /> COUTRIM-GR: 6f EDT & SODS COP?STRUT TIOU, I13C. =R WITH H YDR13CARBOUS <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 labelediplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.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)(d I am a large quantity generator)or(b)(i11 am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> 2.4^4 w i <br /> 16.International Shipments <br /> 1-- ❑Import to U.S. El Export from U.S. Port of entrylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> t1. 17.Transporter Acknowledgment of Receipt of Materiats <br /> Li Li Transporter 1 Prmtedrryped Name Signatu Month Day Year <br /> C-1 <br /> aTransporter 2 Pnntedrfyped Name _ - - - - Sg at - - Month --Day -Year- - <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity G� ❑T ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Reoc smiled quantitv. 25 I with Iii on - �2- <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> U <br /> LL Facility's Phone: Month Day Year <br /> W 18c.Signature of A temate Facility(or Generator) <br /> a <br /> z <br /> � rn <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. OV 12. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certifirabon of receipt o1 hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name S Month Day Year <br /> %�o� :�',/"�ZP4 le)I I I-VI 14 <br /> EPA Form 8760-22(Rev.3-05) Previous editions are obsolete. ©DES NATED FACT ITY TO DESTINATI TATE (IF REQUIRED) <br /> 11687.1886 ODuY <br />