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EPA Form 8700.22 (Rev. 3.05) Previous adilions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />TP <br />UNIFORM HAZARDOUS <br />I. tienemlor lD Number <br />2, leaga i of <br />3. Emergency Response Phr✓- <br />1.OO <br />14. Man fat Tracking <br />0111 <br />Number <br />8 DAT <br />WASTE MANIFEST <br />5. Generalote Name and Meiling Address GBnerators Site Add•esa (f different than meipnq address) <br />50 WIN COUNTY PUILIC VORKS IEPARUOT SBR JIMIN COUNT PYILIC UORKS IEPARTHENT <br />1119 EAST HAZELTON AYAJIUE 17121 E. HRRNEY LAME <br />Generator's Phone; STOCKTON CA 95211 (219)461-3166 LOII CA 95241 12191461-3116 <br />6. Transportar, 1 Company Name U.S. EPA ID Number <br />21st Century Environmental Management of California LP CpRIl0U21TIK <br />FZ <br />7. Transporter 2 Company Name U.S. EPAID Number d <br />8. Designated Fadlly, Name and Site Address U.S, EPA ID Number <br />GENERAL ENIIRONKENTAL NGT, LLC ANI PSC ENIIIOAIIENTAL SERYI 11' f <br />,k—r 1'E <br />INITE ROCK ROAD ! <br />11155 FNVIRONME <br />_ <br />FMIIIt 3P11011a: Q D 4C�'T'_r^-O("7Tmri <br />W. <br />9b. U.S. DOT Description 8nduding Proper Shipping Name, Hazard Gass, lO Ntunbel10•Confainere <br />11.'fabd <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />mW PacNng Group (Il any)) <br />Quanthy <br />WINcI. <br />I UR1263 PAINT RELATER MYERU L 3 PUT "T -5P11624 <br />612 <br />R <br />x <br />04 <br />GF <br />IWO <br />P <br />-- <br />— <br />2. UNIMERSK VASTE LIVIPS <br />t7 <br />o� <br />4ZO <br />P <br />a. EMPTY 1�RJMS F -or <br />Ite <br />PF <br />n. <br />14• Cadet Hmldliog Instructions and AddiBood lnforowtun <br />(l) IESO1351-11 - MUM WORK OIL MISE P 12) $31=955-11 FLUORESCENT TUNS, I. ALL WE IS ElIE11PT RMSEHOLI <br />AR701110115 905TE PER 110261.46, <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: Ihereby declare that the corneas of Ina consignment are fully and emuretety desrn'6ed above by the proper shlpping namC,01%I arc doSsiFied, puckagod, <br />marked and labelecilplacuded, and are In all respects In Droner condition for transport eoaoNing to applicable International and rhmon d govemmcnlal regulations. If export Shipment and I am the Pdnary <br />Exporter. I mr ity that the contanis of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, <br />I c9r8N that 01r: waste mioirnixali statement identified in 40 CFR 292.27(o) (if I on a Woe guantily, yurreralur) or (b) (if I ran a smell quantity generator) is M. <br />13ensralor'srogeroe6 PrinledRypod flame Signewre Month Day Year <br />.r <br />F- <br />16. International Shipments <br />❑Import to U.S. ❑Fxpon ham U.S. PON 0l entrylexill __... ......._.....- <br />= <br />Trialpipodar signature(lor emporia orgy): Dole leeving U.S.: <br />� <br />17 nerAcknavlet�mmt of Recalpl ofMalalals <br />TM ptnU 1 Printod/fyp tl Nam 5 score Mogh Day Year <br />IrNWAef ri YnYTypg Name Signature Month Day Year <br />16. Discrepancy <br />IN Discrepancy indication Space ❑ GUantily 1:1 Type ❑Residueq <br />❑Pemel Reledlon ❑FutlR edion <br />Manifest Reference Number: <br />186.Alte`rna�le Fta}dllty(Or 13000rraalor9U.S. EPA IO Number <br />J�0A <br />�-1^ <br />tar. <br />FadllysPhone: ,(ti. V..m "2[j 1110* <br />tat, Signiilurc ulAlloraa: FOCilily 0 <br />Into) Year/2V <br />Ac / ` <br />Z <br />I07Hazar s este Repot MarlaiIII64aMethod Codes (i.e., codes for hazardous male treatment, disposal and retydinif systems) <br />N141 H141 <br />20, Designated Facility Owner or Operator: Gerfification of recept of hazardous materials. covered by the roulleat except as noted In Item 18s <br />PrInecillyped Name 5lgnature Month Day Year <br />EPA Form 8700.22 (Rev. 3.05) Previous adilions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />TP <br />