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Please print or type. (Form designed forum on elite (12-oitchl typewriter) _PA Form 8700-22 (Ree 3.05) Previous editions are obsolete. - I ( DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) renin MPPiuveu. memo rvu. zvou-vuju UNIFORM HAZARDOUS I -Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin Number FEST WASTE MANICAH111001044 2 (500}4;?_I_171H 00038859 FLE .Generaloes Name and Mailing Address_ AT'I'N:KIMBPA ANDREWS Generator's Site Address(i1 diterent than mailing address) `AN JOAQUIN COUNTY SAN 1810 E HAZLETOPJ V -IPJ HOUSE n. JQA-rt HOLD A ZARDCIUS WASTE STOCKTON CA, 95201 FACILITY FORD STREET (209) 46'8- x06'6 A Generator's Phone: STOCKTO CARGDG 6. Transporter 1 Company Nam U.S. EPA ID Number CLEAN HARBORS ENV. ^ERVICE'3 ftizkD 1:'39?;'2250 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name anQ Site Address CLEAN HARBOR -S ENV.FPVTC ^ U.S. EPA ID Number E.:, x09 AMERICAN r'iRCZE r ELDORADO, AR 71730 Facility's Phone: ('371))8Fr_•-71-13 AIR D069748192 ga. 9b. U.S. DOT Desadptmn (including Proper Shipping Name, Hazard Class. ID Number, Containers . HM and Packing Group (if any)) 12. Und 13. Waste Cotler . Wt.Nol.(ERG: 12(PF:744520) !Ne jQjuant w 2 _ U X N. O.S., 4. 1, UN132�, PGII, (PRG: 131), (PF:749521) C E P L-ODAN FLAMMABLE, TOXIC, O O X ,C{LGRODAIQEI 3 11N. ( 1) -,r) 6.1),UN3121,PGII, (ERG-:rl (PF:74g522) fi6'2N/rl'�E .(.), D M F Ov a. COP,ROSIVE LI40UID BASIC ORGANIC, X TJ-O-S-,8',U113,67,bGI I, (�RG:153), (PF:769887) 14. Spedal Handling Inslrudions antl Atltlitional marmairm 00 D E do 37 P 1: 7945:10, 9 X55 DF,2: 7945'1, -��X MBCF, 3: 749522, / � a r �-$ „ _ r 1)M, 4: 7r -)98H7, `:�_X 55 D b # �(� X5 15. GENERATOR'S/OFFERq'R'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping lame, and are dassiled, packaged, marked and labeledlplacaded,ond are 11 111 respects in proper condition for banspon ingl a according to applicable international and national governmental regulations. If shipment and I am the Primary Exporter, I cer fy that the Contents of this consignment conform to Me terms of the atlached EPAAckrrowletlgment of Consent certify that the waste minimization statement idenlifad in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is We. r) Generator' Odarors PdnmIlTyped Name igna - J on/ ay ear -r 2 16. Intemarsmal Shipments [ / ❑ Impod to U.S. ❑ Expen from — U.S. Pod of entry/exit, Transporter signature for exports MIXI: w vi 17. TranspoderAcknowletlgmenl of Receipt of Materials Date leaus.: Transpoder t Pdn Rped Name Igna on ay ear �'J`Ah �yl h Q 16 Tmnspoder 2�igkaPrinled/fypetl Name I��lo/a6 � lure month Day Year } 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejection ❑Full Rejection 18b. Alternate Facility (or Genelalw) Manifest Reference Number: J U.S. EPA ID Number U Q LL 's W, Facili Phone. ofAlternale Fadkty(or Generator) zMonth Day Year 19. Hazardous Waste Report Management Method Codes (). e., codes for hazardous waste treatment, disposal, and recycling systems) p 1. 2. 8 4 1 20. Designated Facilily Owner Or Operator; Certftfion of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name Signature I Month Day Year _PA Form 8700-22 (Ree 3.05) Previous editions are obsolete. - I ( DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)