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l <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) rtnApproved.-OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response PhoneI'M5879660 <br /> cking Number <br /> WASTE MANIFEST CAD98204295a 200-369-2701 JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address(If different than mailing address) <br /> Lodi News-Sentinel <br /> 125 North Church Street - <br /> Lodi.CA 95241 t.. <br /> Generator's Phone: 209-3.69-2761 <br /> 6.Transporter 1 Company Name_ - U.S.EPA ID Number <br /> CaWomia Environmental 8 Litho CARDOOOO9910 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Asbury Envimnmental Services CA00282770M <br /> 8.Desi Hated Facility Name and-Site Address U.S.EPA ID Number <br /> iemens Water Technobgies Corp. CAD007030M <br /> 15�3os Ango AN <br /> esle , .AaB <br /> Facility's Phone: 323-277-1500 <br /> ga 9b.U.S.DOT Description(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 Wt.Nol. <br /> 0 1 Non RCRA Hazardous Waste,Liquid(Waste Ink) DM , I� P 331 <br /> (90/ Z <br /> 2 2. <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1.Waste Ink ERGtk171 <br /> 15. 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 lbbeled/placarded,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 conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mini ization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) if 10 a s all quantity generator)is true. <br /> GeneratorslOfferor•s P' R Y N � �- Signature Month Day Year <br /> ✓ - Z 1 <br /> -J 16.International Shipments <br /> p- ❑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 /> l' TransppW V,antE�Q.voed Name Signature Month Day Year <br /> O ����YY Ti <br /> a <br /> Transporter 2 Printed/Typed Name Signature VMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> as19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <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 I <br /> PrintedrTyped Name Signature t. Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> r � <br />