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Please print or Npe.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMt3 No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator_€D Number- 2.Page 1 of 3.Emergency Response Phone4.h9aniEest Tracking Number <br /> WASTE MANIFEST :a JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 'SION <br /> 77-10 �St�Ji�1tA'Y- . <br /> �. nR• r ;r r 95210 <br /> Generators Phone: 209--478—•9971 <br /> E.Transporter 1 Company Name U.S.EPA ID Number <br /> :!PCF Rr-COVERY SERVICES <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> .. :z SERVICES <br /> FAS' kCC BLV6 <br /> '':,Ell CA 90.023 <br /> Facility's Phone: (PM, ) 4`9-7145 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.lvol. <br /> C P A I I*j <br /> o ?GIT_4 RQ, (D0f1) <br /> iM p� A <br /> z ZNON RCRA HAZARDOUS WASTE LIQUID (WATERIl 1.33 <br /> CLEANING SOLUTION) (CALIFORNIA REGULATED <br /> 3f6A46 94. <br /> �] G <br /> - --I <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> :-.� ii_•�.I IGv ..;v.jf I'If-�� �W.Jr -..� l,y"- - -ii. _ _.. -- <br /> 6LOVES, GOGGLES & PROTECTIVE CLOTHING :•24HR EMERGENCY CONTACT: KIRK WALDORF <br /> GRID#: 9bl) 128 9b2) NONE IIINIII�IIIIIIl1�11111111fllllilillllllllllllilllll�ll <br /> 15. GENERATOR'SfOFFEROR'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 in proper condition for transport according to applicable international and national gevemmental 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 /> certfy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f l am a small quantity generator)is true. <br /> GeneraterslOfferors Printed/Typed Name g lure Month Day Year <br /> -i 16.Intematlonal Shipments <br /> F1 Ill to U.S. ❑Export from U.S. Port of entrylexit; <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materals <br /> TranspDftef-J1-�Printedlfyped Name Month Day Year. <br /> Q Transporter 2 PdntedlTyped Name mature Month Day Year <br /> F- <br /> F <br /> 18.Discrepancy <br /> 1Be.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partici Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 1Bb.Alternate Facility(or Generator) U.S.EPA iD Number <br /> .�r <br /> V <br /> Facility's Phone: <br /> LLS 18C.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3, 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as need in Item 1 as <br /> Pr ntedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-06) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />