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Please print or type (Form designed for use on elite(1 2-1typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �[ <br /> WASTE MANIFEST JJK_ <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> .,SSOCIATED Till Se-OV;C`115 =l <br /> 323 WEST CHARTER VVYA`r <br /> STOCKTON,CA 967% <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 'AJAOS EVARONMi RICES <br /> 7.Transporter 2 Company Name Z4U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address _ U S.EPA iD Number <br /> �;�.:fl='fL"�ct✓roL>.:Pt;E ftFCO��P-y <br /> 5150 EAST MO BOM15)'A.F't"3 <br /> t 1151.NN17;1`4 Fw,C4. 9fm.,A <br /> Facility's Phone; <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 10,Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type {Quantity Wt.Nol. <br /> a � <br /> ILL! 2 <br /> LU <br /> ch <br /> s. <br /> 4. <br /> 14,Special Handling Instructions and Additional InformatiDn t' <br /> } �J <br /> 1, <br /> 15. GEN ERATOR'SIQFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,end are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors PrinledlTyped Name Signature Month Day Year <br /> —+ 16.International Shipments <br /> F— ❑Import to U.S. Export from U.S. Port of enlrylexit: _ <br /> Z Transporter signature(for exports only(: Date leaving U.S.', <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/Typed Name Signature 4 Month Day Year <br /> O <br /> CL <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantityyp J <br /> ❑Type Residue ❑Partial Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> K Facility's Phone: <br /> w 18c.Signature ofAlternate Facility(or Generator} Month Day Year <br /> t— <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LL <br /> 1, 2, 3. 4, <br /> 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 6700-22(Rev 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />