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Please print or tune. (Form designed for use an elite (12 -Pilch) tnewriter.) <br />Form Approved. OMS No. 2050.0039 <br />EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page i of <br />3. Errsrgency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />C A L 0 0 0 3 6 6? 7 Z <br />1 <br />($00) 424-9300 <br />014051077 JJ <br />5. Generator's Name and Mailing Address Generators Site Address (it different Than mailing address) <br />xIREiTONE #028746 <br />720 E. HAMMER LANE �� 3 <br />STOCKTON CA 95210 <br />Generatoes Phone: <br />6.Tr-�,; r"rACycm� 'INMENTAL SERVICES f� nn'� tt$.FAAION*beV ti ;e f / U.3 b <br />1. Transporter 2 Company Name U.S. EPA ID Number <br />-NIf ( k.. <br />at <br />8. Des' nated Facility Name and Site Address a a 4 ., : ;r. n Q`' k PC Alt ' U.S. EPA ID Number <br />WATER TEC*10LOGIES-LLC _. <br />5375 SOUTH BOYLE AVENUE <br />LOS ANGELES -CA 90058 <br />C A._ C)- 0 9. 7 0 3 0 9 9 3 <br />FacililysPhone: (323) 277-1500 <br />ea <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No <br />Typo <br />HM <br />and Packing Group (t any)) <br />Quantity <br />Wt./Vol. <br />1'tarim nrma TT4h,7nonntre maS Pw SOLID (nTL.v SnLION f <br />,..,. <br />352 <br />o <br />0 <br />L5 <br />/D <br />l <br />MP <br />_ <br />�i <br />2. <br />ILL! <br />_ <br />I <br />3. <br />4. <br />LL <br />14. Special Handling Instructions and Additional information <br />3-4.ERGENCY CONTACT , CI MTREC 1-800-424-9300 NAERG# 9B1 : 171 * PROFILE 0.9B1 , <br />P20SS24 OILY SOLIDS * PO# A110215085 * APPROPRIATE PERSONAL PROTWTIVE EQUIPMENT <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shfppiag 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 governmental regulaffons. 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 cert fy that the waste minimization statement Identilied In 40 FR 262.27(a) (if i am Marge quantity generator) qko I amwof qua bty generator) is true. <br />Genera t ors fin y Name Signa Mo Day ear <br />.r <br />i6. In erna! onal Ship ,e s II�'11 <br />L� Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. TransporterAcknowfedgment of Receipt of Materials <br />Trans 1 PrintedfTyped Name Signature Month Day Yea; <br />r . <br />0 <br />co <br />Transporter 2 Printed7fy d Name gnature Month Day Year <br />a <br />r•- <br />18. Discrepancy <br />18a, Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />ecbon <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />.a <br />U <br />U< <br />Facility's Phone: <br />C1 <br />18c. Signature of Alternate Facility (or Generator) <br />64onth Day Year <br />C <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1. <br />2. <br />20. Designated Facility Owner or Operator: CeniFcaWn of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month Day Year <br />EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />