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Please orint or tvoe_ (Forte desianed for use on elite (12 -pitch) typewriter.) <br />Is F f SC.- RR?• 12- 2O'R4- <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. \ —DESIGNATED FACILITY TO DESTINATIO�STATE (IF REQUIRED) <br />0077.1680 <br />UNIFORM HAZARDOUS - 1. Generator ID Number <br />2. Page 1 of <br />F3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 001421234 JJ <br />WASTE MANIFEST CAL000298751 <br />1 <br />209-612-6M <br />5. Generators Name and Mating Address Generators Site Address (d different than mailing address) <br />F 8 H CONSTRUCTION 4945 E. WATERLOO <br />P.O. BOX 55245 <br />STOCKTON, CA 95213 <br />STOCKTON.CA 95205 <br />Generators Phare: 209-931-3798 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SHOP HAZARDS SOLUTIONS CA0000648497 <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />U.S. EPA ID Number <br />8. r oto So$SaraA w, <br />LLC. <br />11855 WHITE ROCK RD. CAD900884183 <br />RANCHO CORDOVA, CA 95742 <br />Fadtitys Phone: 916.351-0980 <br />9a. <br />9b, U.S. DOT Description (mdudrg Proper Shipping Name, Hazard Class, ID Number. <br />10. Containers <br />11. Total <br />12. Unit, <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group (d any)) <br />Quantity <br />WI.Nbl. <br />1• RQ, WASTE FLAMMABLE LIQUD, N.O.S., 3, UN1993, 9 (PETROLIUM <br />1 <br />DM <br />55 <br />G I <br />DOW F005 <br />331 <br />o <br />DISTILLATE, TOLUENE) (D001,F005) <br />Z <br />2 <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />PROFILE #88758, SOLVENT BASE CONCRETE RELEASE, GLCOSEAL 2000 <br />APPROPRIATE PROTECTIVE CLOTHNG <br />SEE ERG #128 <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 labeled/placarded, and are in all respects M proper condition for transport according to applicable international and national governmental regulates. If export shipment and I am the Primary <br />Exporter, I artily that the contents of this consignment conform to the terms of the attached EPAAciuwwiedgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (d I ern a small quantity genendoo is true. <br />Genrs/0lferors PrintW!7rypqNSignature 4 Month Day Year <br />�- s -,(!Z Liz <br />- r <br />1 . ntematlonal Shipmentsmport to U.S. ❑ Export from U.S. Pon afentry/exit <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materiel <br />Transporter 1 Pdntednyped Name Signature Month Day Year <br />Transporter 2 rintedfNam NaSign Day ear <br />F <br />_ <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ElPartial Re)edah ❑Full Rejectorh <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />sa+. <br />Facility's Plane: <br />18c. Signature of Alternate Facility (orGenerator) <br />Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal. and recycling systems) <br />® <br />i. <br />2 <br />3. <br />4. <br />I 1..� <br />20. Designated Facility Omer or Operator. Certification of receipt of hazardous materia covered by as noted in Item 18a <br />P' ted/T arms Day Year <br />6./I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. \ —DESIGNATED FACILITY TO DESTINATIO�STATE (IF REQUIRED) <br />0077.1680 <br />