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it <br /> 41 <br /> Please print or type,(Form designed for use on elite(12-pitch avidtec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t.Generator tD Number 12.Page 1 of 3.Emergency Response Phone 4.Mantfaat Tracking N4mbw' <br /> WASTE MANIFEST CSI 1 1 4 13$772 <br /> 72450 FLE- <br /> S:GeneraWs Name and Mailing AddressGenerator's Site Address(d different than mailing address) <br /> (JNWtMSALSVr—RECYCUW MnWHamMemWma <br /> 3203 S.EI Dorado St. <br /> Stock-ton,CA <br /> Generator's Phone; <br /> 5,Transporter 1 companyName' U.S.EPA 10 Number <br /> Urfaon Pacffio bw CO <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Me Address U.S.EPA ID Number <br /> 1111 Mast HVwvay 123 UTIRMOM7 <br /> Faafitys P 1 Eaot Caton.Ur 84620 USA <br /> ga• ib.U,S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Contakrars 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No. ` Type Quantify WtNol, <br /> 0. <br /> 0.B{'SfIB P't."�F"4&2 fd YG."•4C:P'.P 3[9d'%`P$" i"�Ytt- .. -J <br /> Jl lW9t �� <br /> sv�rrrt aha t, a avnr tsvarrruttt f ) ,B 7 f <br /> � 2 <br /> _ . . <br /> Uj <br /> 4 <br /> „t,4.§pedal Handling InsWctlons arid Additional Information <br /> LwNtIRVIL SEPAM WYCLINGRAILUP NO, 5 6 X 91/ 5 <br /> g;t;tr•RCRA, or RtVfta <br /> 040,41 1&OWS <br /> 15. GENERATOR,SIOFFFRPR'tCj it11FICATIONt I hereby declare that the 66r�to of tMeoons gnirient are fully and eauratety described above by the proper shipping name,and are dassihed,packaged, <br /> marked and labeted1placarded,end are in all respects in proper condition for transport according to applicable International and national govvemmantal regulations.If export Shipment and I am the Primary <br /> Exporter,I cartify that the contartb of this consignment conform to the tame of the attached EPAAdewvfedgment of Consent^ <br /> I certify that the waste minhization satement Identified in 40 CFR 262.27(a)(fl am a large uanthy generator)pr(b)Qt I am a email Qumrtity generator)is true, <br /> are e w e t ypad lama Day year <br /> t <br /> _J 15,International Shipments _. <br /> P- ❑In, <br /> port to U.S. ❑Export from U.S, Port f antrylexit _ <br /> Transporter signature Ior exports only); Date leaving U,S.: <br /> i s'17. 44 <br /> ransportar l r n 'tram® eara �y.. <br /> a � � -- = - <br /> Trans z .rnfadf7 ay ear <br /> _ porfer ypeil'Name nature <br /> ti <br /> 18.Dlsaeparxy ; <br /> 18a.Discrepancy fnd ration Spada ❑ Quantity Type Residua ❑Partial Rajactias ❑Full Rejection <br /> tftitast Reference Number: <br /> 18b:Alternate Faa'ih+(or Ger rata) <br /> U.S.EPA 10 Number <br /> =i <br /> ti <br /> 4 Fadli s Phone; .. <br /> LU 18c,Signature'ofNtemate Facility(or Genamtor) <br /> kfonth Day Year <br /> 10.Hazardous Wastage .. <br /> pert. anagamenif da rai Cis(is for hazaNeus waste lma ment,disposal„and recyding systems} <br /> 14 <br /> 2b.Designated Fadity Ovrner of Op rataf CNfica4on of.retxnpt of E materials covered by the maresi except as noted in(tem 1 Be <br /> PrntedlTypedName ignature' y Year <br /> t <br /> i EPA Form 8700-22(Rev,3-05) Previous editions are.ottssolate: i <br /> r DESIGNATED FACILITY TO GENERATDR <br />