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Please print or We, (Form desiqned for use on elite (12 -pitch) typewriter.) Form Approved, OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone7012850234 anifest Tracking Number WASTE MANIFEST CAL 0 0 0 3 8 8 5 3 8 1 (BO� 36,477 J J K 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) QBR INC 2-3-25 W CKAIRTER iri+AY 2325 W CHARTER WAY STOCKTON CA 95206 5 CA 95205 „ r " Genera tors Phone: 20945743490 13 fi. Transporter 1 Company Name $ U.S. EPA ID Number ENVIRONMENTAL RECOVERY 5ERVICE5, INC. C A R 0 0 0 18 8 2 01 7. Transporter 2 Company Name. EPA ID Number ��of ICT�RIt9 Cd1RlC 132014 CA R 000187922 I1V�l / fltVY JVFVJ 8. Designated Facility Name and Site Address S. EPA ID Number RINECO HEALT 1007 VULCAN ROAD. HASKELL EWRQNMENTAL BENTON AR 72+015 DEPARTMENT FaciliVs Phone: MI)778-9M IA R t7 9 8 1 0 5 7 8 7 0 9a. 9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WtNol. i. UN12153, WA57E PAINT RELATED I M4TER01, 3, PG III DOD1 D035 F003 D M 2(_} F Ft7 _31 W z W -�.. 3. 4. 14. Special Handling Instructions and Additional Information 9131111405- - %VA5TE PAINT RELATEDWTERIAL5INCANS 2-CERG4:951.128"ER5Vd.U.li1O=-ECB" 24 HR EWRGENCY CONTACT: ENVIR05ERV 15, GENERATOR'SlOFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) tiff am a small quantity generator) is true. Generato sl0fferor's Printed/Typed Name Signa re Month Day Year G"14" t r + — J l— 16, International Shipments ❑ Import to U.S. ❑ Export from CftS. Port of entryiexit: Z Transporter signature (for exports only): Date leaving U.S.: 17. Tra porter Acknowledgment of Receipt of M rials F- Trans orter 1 PrinteOyped Na signature Month Day )tear 0- JJ ! ' r� �II QTranspo er z 'nte yped Name Signal Month Day Yea t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type❑ ❑ Full Re Residue Partial Rejection Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U tai Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) � 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certificatiorrof receipt of hazardous materials covered by the manifest except as noted in Item 188 PrinledlTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.