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a <br /> or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> .rIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAr Oooataa62 X09 -3�uo 014374342 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Manteca Bulletin N <br /> P.O.Box 1858 27B Button Avenue J 1�"} <br /> Manteca,CA 95336 Manteca,CA 95938 <br /> Generator's Phone: 209-249-35W <br /> 6. G _ <br /> Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> California ErWironmental&Litho <br /> 7.Transporter 2 Company Name gMM U S.EPA IDC/N4uRmber�t <br /> Rust and Bons '�^''rij r.)1:0A 0T""��' <br /> 8.Designated Facility Name and Site Address <br /> r�Raoo1B79z <br /> EvoQua Water Technologies LLC U S.EPA ID Number <br /> 5375 5.Boyle Avenue CAD0970309A3 <br /> Los Angeles,CA 90058 <br /> Facility's Phone: 393:277-15W t <br /> ga. 9b.U.S.DOT Description(including Proper i I Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total12 Unit <br /> 1. <br /> No, Type Quantity WUVol. 1 .Waste Codes <br /> C, Non RCRA Hazardous Waste,SaW,(Wane Ink) <br /> LU <br /> ao DM 30 �- 954 33I <br /> LU 2. <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1.Waste ink ?Q 1 ERG*171 <br /> LExporter, <br /> 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 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 /> I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signat <br /> Month Day Year <br /> �� 7 <br /> 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.' <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp eeul hr 1 1.4rited/T ped Name Signature <br /> p8rV13,r MonthDay Year <br /> �� -7JZZ Transporter 2 Printed7Typed Name Signatu e <br /> hMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> 18b.Alternate Facility(w Generator) Manirest Reference Number: <br /> U.S.EPA ID Number <br /> U <br /> ua Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day. Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W <br /> 1. 2. 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 /> Prin ed/Typed Name Signature <br /> Month-75-ay—Yea, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> 0LC-1 i'JKl VACVI_V VY'l D-ES-i'INIAr IONI S7ATP tat: Qt-n, <br />