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283041-16 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />2578430 <br />Form ADDroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />14. Manitwl Tracking Number <br />WASTE MANIFEST CAH111001044 <br />1 <br />( 877) 577-26691000157507 <br />DAT <br />S.Genemtcrs Nameand Mating Address . Generators Site Address III diflersnl than mailing address) <br />SAN JOAWIK CO. PUBLIC VORNS - ORI6IN: STOCKTON PHHff SAN JOAQUIN CO- PUBLIC VORKS DEPT/STOCKTON PWICF <br />1010 EAST HAZELTON AVENUE 71150 R.A. DRIBUTORD STREET <br />Generator's Phone STOCKTON CA 95201 (2091460-3065 STOCKTON CA 95206 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st Century Environmental Management of California, LP CAR000210617 <br />7. Tran Company am U.S EPA ID Number <br />/ 4 <br />4erf <br />8. Designated Fachty, Name arid Site Address U.S. EPA ID <br />RINECO CHEMICAL INDUSTRIES, IN <br />1007 Vulcan Road <br />Feruli YPnnna ARD931057870 <br />9a <br />9b. U.S. DOT Descril Ihcluding Proper Shoo Name. Hazard Class, ID Number, <br />10. Containers <br />it <br />12.Unt <br />HM <br />and Packing Group (if aluanyal <br />uenit <br />Qy <br />WtNOI. <br />19. Waste Codes <br />No. <br />Type <br />UN1263 PRINT RELATED MATERIAL 3 P&II DOT -SP -11624 <br />612 <br />w <br />X <br />/ <br />CF <br />7z7 <br />1 r <br />P <br />z <br />2. <br />w <br />dJ <br />3. <br />177-717771 <br />4. <br />ENV <br />14. Special Handing Irnbucuons and Additional Information <br />(l) 140505771-02 - ER6112IJ PRINT RELATED MATERIALL VASTE IS EXEMPT HOUSEHOLD HRZARDOUS WASTE PER 46CF1251.46. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I herebydedare that to contents of this consignment we fully am accurately descnded above by dile proper slipping name, and ared9sslfied, packaged. <br />mated and labeled0warded, and are in all respects in propel condition for transport according to applicable international and national governmental regulations. If export stipment aril I am the Primary <br />Exporter, I cenpy that the contents of On consignment conform to the term of the ah2rled FPA Atlmoele"ir t of Consent <br />I certify that the waste minimization statement identified n 40 CFR 262.27(a) (d I am a large quenbty generator) or (b) (if I am a smal quantity generator) Is the. <br />GenemtorsiWemrs PriMedfTyped Name 0�� � Signature Month Day Year <br />Z'ol G 1 lb <br />J <br />F <br />16. Internalwnal Shipments <br />❑ Import to U.S. ❑ E.Pon ham U.S. Port of a tryrelds <br />Transporter signature (for exports only) Date leavig U.S.' <br />17. Transpoder &1m lodgment of Rei of Materials <br />Tra 1 Pmtedlfy Na Sig ue <br />MonN IDa Year <br />y <br />►'l1 Q WY ':dI <br />C <br />Q <br />Transport Bed IIy a Name /f\ Sign Month Day Year <br />2 .0111A <br />18 Discrepancy <br />1 <br />lea. Discrepancy Indication Space ❑ Quantity El Type D ResiduePamal Re neon <br />❑ je ❑Full Rejection <br />Manrtest Reference Number. <br />Z <br />Ifib. Aftemate Fadllty(or Generator) U.S. EPA ID Number <br />J <br />U <br />seri <br />Fadltys Phone, <br />w <br />fill Signal of Alternate Faciil Generator) <br />Month Day Year <br />Q <br />2 <br />N19. <br />Hazardous Waste Report Management 6fedrod Codes ite„ codes for hazardous wash beaonent, deposit, and recis irg systems) <br />7. <br />2, 3. <br />4. <br />20. Designated Fedliry Omer or Operator CedAralan of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />1 <br />' IedR Name <br />Sig lure Month Day Year <br />a Ilk <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />