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L` <br />Please orint or tvoe. (Form desianed for use on elite (12 -pitch) typewriter.) <br />10 FrfSr'. RR1.7:2' 20:8.4 <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 />110077.1680 <br />UNIFORM HAZARDQUS _ <br />1. Ge°erator ID Nwnbar <br />2. Page i of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 001421234 J <br />WASTE MANIFEST <br />caL000208751 <br />1 <br />209.812-69M <br />S. Generators Name and Mailing Address Generators Site Address (d different than mailing address) <br />F 9 H CONSTRUCTION 4945 E. WATERLOO <br />P.O. BOX 55245 <br />STOCKTON, CA 95215 <br />STOCKTON. CA 95205 <br />Generators Phone: 209-9311-3798 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SHOP HAZARDS SOLUTIONS' CAO®00848497 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. De MWW ppb ' dress U.S. EPA ID Number <br />ux <br />11855 WHTE ROCK RD. CAD980884183 <br />RANCHO CORDOVA. CA 95742 <br />Facility's Phone: 916 -351 -OM <br />9a, <br />9b• U.S. DOT Description (induding Pmper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codas <br />No. <br />Type <br />HM <br />and Packing Gip Cd any)) <br />Quantity <br />WtNol. <br />1• RQ, WASTE FLAMMABLE LIQUID, N.O.S., 3, UN1993,11(PETR000M <br />1 <br />DM <br />55 <br />G <br />D001 FOOS <br />331 <br />o <br />DISTILLATE, TOLUENE) (DOOI,FOO5) <br />Z <br />2. <br />LU <br />c� <br />3. <br />4. <br />14. Spew Handling Instructions and Additional Information <br />PROFILE #88758, SOLVENT BASE. CONCRETE RELEASE, SILCOSEAL 2000 <br />APPROPRIATE PROTECTIVE CLOTHING <br />SEE ERG #128 <br />15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and acamd* described above by the proper shipping name, and are classified, packaged, <br />marked and labeted/oacarded, and are in all respects In proms condition for transport acceding to applicable international and nasi governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (d 1 am a large quantity generator) or (b) (if I am a anag quantity generator) is true. <br />Gert s/Offerors PrkntedlTyp N Signature �, Month Day Year <br />I / j.'(2 d <br />E . <br />1 . ntemationai Shipments <br />❑ Import to U.S. ❑ Export bon U.S. Port of entry/exit <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TransporterAck nowhedgment of Receipt of Mater <br />Transporter i Printed/Typed Name S4nature Month Day Year <br />O <br />0 <br />i <br />J r <br />Z <br />Transporter 2 Firintedirryped Name Sign th Day ear <br />t- <br />18. Disaepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejection ❑ Fug Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />FadWs Phare: <br />18m Signature of Alternate Facility (orGenerator) <br />Month Day Year <br />Z <br />y19. <br />Hazardous Waste Repot Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />2 <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by th as noted in Item 18a <br />MQtrth Day Year <br />(VlI <br />P' tedlT ane'Tom <br />o <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. \ DESIGNATED FACILITY TO DESTINATIO STATE (IF REQUIRED) <br />110077.1680 <br />