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A-8/15/2013 14:20 20952?- 'S BOYETT WAREHOUSE- PAGE 09/13 <br /> +-Go s �oT,Mail a copy to: ?�� X P.0,Btu��+ :sacs^mento;C Owl <br /> 2-04 Athill 30 days. <br /> Please print or type.(Farm designed for'B6 on elite(12-pit(Ih)type,vriter,) Form Approved.OMB No. 0504)038 <br /> i Generator ID Number -7 2,Peg_1.o t 3.Emerpenty R�Spon-%Phone b.Man-fest Tracking Number <br /> UNIFORM WASTE MANIFESTU3 /j�ij,�)6 e' .�"` � u- d �d J J K <br /> 5.Generators Name and Mailing Address"�+ / Ger.. c:r5 Sli�An.re s i f dTer=_n ' n mann dress <br /> �1 'z ��� <br /> Generator's Phone: ` <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> CADSS 192 f'1 2013 <br /> 7.Transporter 2 Company.Name U.S.EPA 10 Nu nbar <br /> mFNTAL <br /> a.Designated ac it y Name and Sita Address y U.S.EPA ID Numb }iEALTH DEPAATME <br /> .�-Vfir�y"m 1011,i#'YC:. t"'r <br /> .I-, 9&0f�37418 <br /> Clwat? Si�,��lfY. <br /> Facility's Phone: 1-3-T9S-Ta'00 <br /> ga; 9b.U,S.DOT Description(including Proper Shipping Name,Hazard Class,tD Numb:Er, 10.Containers 11.Total 12 Unit 13_Waste Codes <br /> HM and Pecking Group(if any)) No. Typa Dx;ntRy <br /> 114e; r, <br /> i <br /> a. + <br /> 1 <br /> 14.5 ar a!Handlin Instructlons and Additional In tion 71, ^ <br /> c15. GENSRATOR'SfOFFERCR'S CERTIFICATION: I hereby dedgre that the contents ofthia consignment are fully and accuratalydescribad above by the proper shipping name,arid are cicssified,paekaraed, <br /> marked and labeled)placarded,and ere in all raspads in properoenditix for transport among to appliteb!e intemational and natlonal govemm M1 regulSCons.If export shipment snd i am the Primary <br /> Exporter,I.certify that the contents of this consignment oonfonn to the tamm of the attached EPAAcknowladgment of Conant. <br /> I certify that the waste minimization statemant identined in 40 CFR 2622T(a)tf I am a large otantity genorator)or(b)(If l ani'a srrrdll rluantip genen3tor)is true. <br /> Gen!2(or'5IOffEro s Pr;nted)Typed Name Sign _—^ Month Day Year <br /> j :16-Intemational Shipments r <br /> Impar to U,S. I J Exportfrom v-s. Pa:t vt en7yrew't` <br /> a Transporter signature(for exports-only): Date leaving U.S.: <br /> u" <br /> ui 17.Transporter Acimowledgment of Rocoot of Mater als <br /> Tnnsp, r 1 Print ped Na;K�� <br /> v}RsatC. � / P�onih DaI Year <br /> 0- ,l [ T /f �/W v Month Day Year <br /> Z Transporter 2 Pdntedfiyped Narni) - fii+-3naP�2 <br /> ix <br /> f- <br /> 18,Dlsrrepancy = 77 <br /> 18e.Digitpony Indlr3tion Space quantity Typr, !_.l RResidue 17 Partial Rcteo6on J Fu�ll'Re]eetlon. <br /> „lariftst Refe-ertce Number: <br /> 18b.Altemate Facility(orGengratar) U.S.EPA ID Number <br /> V - <br /> ci Facility's Phone: Month Day Year signature erAltemate Faculty(crGanerator) <br /> d <br /> a <br /> :1.s,Hazardous Waste Report Management Method Codes(i.e.,coda for hazardous waste t,--itment disposal,and recycling n,00als) <br /> 4. <br /> r. 23. <br /> N135 . <br /> 20.Desipated Facility Owner of Operator-Certification of receipt of hazafdous materials covered Hy the manifest except as ncled in{sem 18a <br /> Ptintednyped Name- 5ignatu �' MorlN Day ear <br /> EPA Form+3700-22(Rev.3-0S)'Previous editions are obsolete. N DESIGNATED FACILITY TO GENERATOR <br />