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DTSC. 02.723. 164.6 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST CAL000378900 1 925 5,98-7910 010403688 JJK <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> PAC-*'310- =ZS i 9 0 rjL f3 19C <br /> 550 U_ 9ALPICO ROAD chi ) IL 11..04 1;J P?2 <br /> TRACY, CA 95376 550 U. VALPIM R02n <br /> Generators Phone: 925 548-7910 Atttn:MGAR RTLSILUJ-a0 TRACY , CA 95376 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ADAi29 SERVICES, 1EC. C8' 0' 00189431 <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 /> L�'7^liL�hO�I 'IILli� <br /> 2000 19- AY,P:MA STREET CAT080013352 <br /> Faalitys Phone: 310 537-74-00 CQt4PTVN, CA 90222 <br /> ga 9b.U.S.DOT Desc ption(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 WLNoI. <br /> 1. <br /> d' <br /> o I70U-RCP,A ➢i&�&DffLUs :�s� LY 17I3} <br /> aQ, CMXER RaTH TP.A1 i HYDR1 CART Z15) Gaai <br /> w <br /> z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> A19bID M CONTE1CT G MEAR RUBBER GIOVES ERG 128 <br /> CORTRACTGP-: 'REMI G S11I3S C013MUCCTIOD, I17C. =R WITH 44Y RGCARB0,US <br /> 15. GENERATOR'S/OFFEROR'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 labeledlplacarded,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 <br /> Exporter,I certify that the contents of this consignment oonfonn to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(41 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferors Printedrryped Name Signature Month Day Year <br /> 24/x( 1/2 <br /> J 16.Intemational Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Part of enlrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prinled/Typed Name Signatu Month Day Year <br /> cn - - - <br /> Q Transporter 2 Printed/Typed Name Month -Day -Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El T ❑Residue Partial Rejection El Full Rejection <br /> R�nQrrrciled uantity. 25� w1f., M�� 14on �2' 111 <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W --[ i 18c.Signature of Ailemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed7Typed Name Si Month Day Year <br /> LA )�k 2, /"ZP4 I e)I I I V1 I I <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. $ NATED FACT ITY TO DESTINATI TATE (IF REQUIRED) <br /> 11687.1886 ©�� <br />