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Please print or type. (Form designed for use on elite (12-Ditchl tvoewriter:) <br />P- e„ --A nano ni Incn_nnao <br />EPA Form 8700.22 (Rev. 3.05) Previous editions are obsolete. <br />UNIFORM HAZARDOUS <br />1,GeneralorlDNumber <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />-V- <br />Manifest Tracking Number <br />WASTE MANIFEST <br />c A L 0 0 0 3 8 8 5 3 8 <br />1(BOM <br />36$-477$ 1 <br />012850227 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />QBR INC 2325 W CHARTER WAY <br />2325 W CRARTER WAY <br />STOCKTON CA 915" 5TOCKTON CA 95114136 <br />Generator's Phone: 209 41157-0490 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ENVIRONMENTAL RECOVERY SERVICES, INC. C A R O O O i B 8 2 0 i <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 />OEMENNOKERDOON <br />N. ALAMEDA 5T <br />COMPTON CA 9D432 <br />Facility's Phone: (310)537-7100 CAT 0 8 0 0 1 3352 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />0 <br />1. NON RCRA HAZARDOU5 WASTE, LIQUID (WATER, OIL) <br />343 <br />TP <br />��25 <br />G <br />w <br />2' NON RCRA RAZARDOU5 WASTE, LIQUID (POLY GLYCOLS) <br />343 <br />3. <br />4. <br />t <br />14. Special Handling Instructions and Additional Information ^� <br />9511357277 - CORE RINSE WATER '[ 2` ERG# : 961. 171, 982. 171 • ER5 W.O.# 103798 - ECB <br />95M 353416OM- BRAKE FLUID 0 X ?y) PV'j <br />ENVIRONMENTAL hE,ALTH <br />24 HR Y <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the p ssified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment apd I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I 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 We. <br />Generator's/Ofieror's Printed,,Typed Name Signa re Month Day Year <br />July - <br />,. ter <br />j <br />f- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from .. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. TransporterAcknowledgment of Receipt of Materials <br />i� <br />Transp , et 1 Printed/Typed Namfi Signature MonthDay Year <br />O <br />a <br />S � , thh <br />/ l/ `Y ✓"t' �J I <br />Q <br />Tran". , r 2 PrintedfTyped Name Signaat re Y Month Day Yegr <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quanti Type Residue <br />ty ❑ yp 1:1 Residue Rejection Full Rejection <br />Manifest Reference Number. <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />55 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU 0 <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br />Prinledrlyped Name Signature Month Day Year <br />EPA Form 8700.22 (Rev. 3.05) Previous editions are obsolete. <br />