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r , <br /> Please print or type.(Form designed for use on elite(12•pllch)typeiyiiler,) Form Approved.OM8 No,2050-0039 <br /> UNIFORM HAZARDOUS ['-Generator 10 umber 2:Page 161 3.Emergency Response PhoneManifest Tracking Number <br /> WASTE MANIFEST C tssosa 1 916-371-7 .47 0 0 6 5 8 7 9 21 JJ K <br /> 5.Generalor's Name and maMNAddress Generator's Site Address(if dlerent than wVN address) <br /> FLAG CITY,SMLL <br /> ER <br /> GeneratVs P <br /> 6.Transporter1 Compalty Name` ' ' <br /> U.S.EPA 10 Number <br /> ,,:(ifyMOS M!IRpNMENTt�I..SERVICE> ., <br /> CAD0440Ja'S58., <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> l S�v sY04 7 <br /> 8.Deslgna ed FW4 Name and S@a Address U.S.EPA ID Number <br /> ,VEOLIA,.ES..TECHNICAL,SOLUTIONS, LLC. CAT08001d079' <br /> 1125 HEI+ISLEY §TREET <br /> RICHMOND;CA.94801 <br /> Faal� s,phon"a:8Q0-243�2382., , <br /> ga, 9b.U.S.DOT Descdp5on(4klu 14V Proper Shlpp!ng Name,Hazard Class,ID Number, 10.Contalners 11.TOW 12.Unit <br /> HM and Packing Group(K any)) 13.Waste Codes <br /> No. Type Quantify 441No1. <br /> XASTE FLAMMABLE SOLID ORGANIC, NOS,4.1 1325; UNPGIII <br /> O GASOLINE,ABSORBENT) <br /> 60 t r)VV1 0-C70 P. <br /> X ?4WASTE GASOLINE,3,UN12W,PGII• 343," : DOO1 0018 <br /> � V1� <br /> 3, <br /> 4. <br /> 14.Spedal Handling lnstructloos and W&nal InformatIon <br /> 9B 1)�R ERGi�i33 9&2)PROFILE#F � dERG#i128 <br /> Csr <br /> HANDLERS SHOULD 9M TRAINED AND,USM RO%MO PPE', <br /> ' L <br /> 15. GEN EkATOR'SIOPFEROWS CEhTINCATION: I hereby dadare that the contents of Ws oohs'nmenl are fulty and accuralety described above by the proper sNpp!N name,and are urasstded,packaged, <br /> marked and labetedlplacarded,and are In a!(respects in proper con&tdon far transport aocordtng to appt',cable Intematbnal and national govemmantel regulations.If export shipment and tam the Primary <br /> Exporter,I certify that the contents of this cons!gorrent conform to the terms of the attached EPAAcknaysdgment of Consent. <br /> I0 Ilial(he wa;te minkntzatlon statement Idenblled In 40 CFR 262.27(8)(K I am a large quantity generator)or(b)(d I am a sma'I quantity generate)Is true. <br /> 44 Generator of!aer s Printe&Typed Name Signature Month Day Year <br /> A n <br /> -.t 6. n�natloila! 'nh _ <br /> ❑Imp& to U.S. ❑EV d from U.S. Port of entry/eft <br /> .-Tr$ns{pf(9(�)gna;tre(for exports only): Date leaving U.S.: <br /> 17.jim AcktAVedgment,of Rocelpt of materials <br /> T porter 1 PdntedlTyped Name S`gna 1.lonlh Day Year <br /> porterPdntedltyped Name Signature Month Day Year <br /> LWIX A. <br /> {8.biscrepancy <br /> 18a.Discrepancy Indcabbn Space ❑ Quantity ❑Type ❑Re311due ❑Partlai Rection ❑Ful Re)ec600 <br /> Manifest Reference Number. <br /> 18b.AHemate Facility(or Generator) U.S,EPA IU Number <br /> U <br /> W Facility's Phone: <br /> Q 18c.Signature ofAltowle Faciity(a Generator) Month DiY Year <br /> Z <br /> N19.Hazardous Waste Report hlanagement Method Codes p.a.,codes for hazardous waste treatment,disposal,and recydiiig systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Faa�ty Owner or Operator:Certification of receipt of hazardous materials covered by Vie manifest except as noted in Item 18a <br /> Prntedyf Mame SgnaNfe flonth Day Maar <br /> EPA Form 8700-22(Ray.3.05) Prevlouseditions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />