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Please print or tvoe. (Form lesioned for use on elite (12-oitchl tvoewriter.) D#-. 00-053).1.243 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions fiFeMblete. DE GNATED FACILITY O DESTINATION STATE (IF REQUIRED) 10293.0165 UNIFORM HAZARDOUS 1 • Generator ID Nunes 2. Page 1 of 3. Emergency Response Phone 4. Man at Tracking Number 0"03235803 WASTE MANIFEST CAL.000298751 1 20"12 -SM. 5. Generators Name and Mailing Address Generates Site Address (d different than mailing address) F 8 H CONSTRUCTION, 4'945 E:: wATERLoo P.O BOX 55245:. STOCKTON., CA, 95205 STOCKTON; CA 85215 . Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number SHOP HAZARDS SOLUTIONS . a . I. CA0000640497 7. Transporter 2 Company Name U.S. EPA ID Number 8. Delated Facili Name and Site Address U.S. EPA ID Number CsEM-R+ HO CORDOVA, LLC. CAD98Q884183. 11655 WHTE ROCK RD. ' ' RANCHO CORDOVA. CA 95742 Fall' sPhone: 91&351-09W ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13 Waste Codes No. Type HM and Packing Group (ti any)) Quantity MNoi. 1 Waste Cormshre Liquid, n.o.s., 6. UN1760,11(trieWerte tetramine) 1 DF P 331 ,z z• RQ; Wade trydrehtorit: Acid, 8; UN1789;11(D002) : - 4 ; DF' .:•n ; •: P. 0002 .791 141 L� 3• RO, Waste Paint Related Material, 3, UNI 263,11(0001, F003) ,. ..1► • P • D001 • F003 , ' 331: , 4. Non-RCRA Hazardous Waste Ligt4d, Watertiese .47 DM'�/ P•: 331- Paint 8 Adhei0ms 7- rYzs 14. Special Handling Instructions and Additional Information MI-PRORLE #R221-76, EPDXY'S WTH AMNES LAB. PACKERGn#154 *12-PRORLE41122176; HYDROCHLOFIfC AaD LAB PACK ERG #157; QW-RRORLE M8089, (9LBASE PAINTS.8 ADH9SIVES, ERG: 128:1IM-PROFILE #1R8097,,;WATER. WE PAINTS 8 AD13OVES ERG #171 t:-: - 15. GENERATOR'S/OFFEROWS 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, marked and labeledfplacarded, and aro in aq respects in proper condition for transport according to applicable International and national govemmental regulations. if export shipment and I am the Primary Exporter, I om* that the contents of this consignment cantons to the terms of the attached EPA mend of Consent. . I ce* that the waste minimization statement Idendfied in 40 CFR 262.27(x) (If I am a large quandly generator) or (b) (If I am a small quantity generator) Is true. Gen r'slOffsrors Printedrryped Name. Signature y ear zgeit..� /'h �� 1 16. International Shipments ❑ Import to US. ❑ Export from U.S. Port of entry/exit Transporter si nature (for exports only): Deis leaving U.S.: 17. TrenspoRerAcknovAedgment of Receipt of Meteriels /71 e 1 Printed/Typ Name31�ature Month Day Y Tra"nsportar ^ Uy 2 Prin ed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial ReJerdbn ❑ Full Rejection Manifest Reference Number. 18b. Aktamate Facility (or Generator) U.S. EPA ID Number v W • Fadlity's Phone: W 1 Sa Signature of Alternate Facility (or nerato) Month Day Year 19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1. , (tee , 1 2. Eb q I L 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted In Item I Se �tnd/Typed Name -^ N r1 Signature Month Day Year Ing -to] EPA Form 8700-22 (Rev. 3-05) Previous editions fiFeMblete. DE GNATED FACILITY O DESTINATION STATE (IF REQUIRED) 10293.0165