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Please print or type. (Form designed for use on elite (12-pilch) typewriter.) <br />Form Approved. OMEI No. 2050-0039 <br />EPA Form omo-22 (R: 3-05) Previous eclittions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />- <br />UNIFORM HAZARDOUS <br />I. Generator ID Number <br />12.Pagelof <br />3. Emergency Response Phone 4. <br />Manifest Tracking Number <br />5. Genetator's Name and Nlaflir Address Generates Site Address (if different than mailing address) <br />FTPX,qTONE 08746 <br />720 E. HAMMER LANE V <br />STOCKTON CA 95210 <br />GeneratoCs Phone: 209 951-2403 <br />6. Transporter I Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />U.S. EPA ID Number <br />2000 N. ALAMEDA STREET <br />Facd-1 F's Phone: (310),5137-7100 <br />9a. <br />9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number, <br />III. Conlaiiii I's <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wf'A/0I. <br />13. Waste Codes <br />No. <br />Type <br />I NODI—RCRA HAZARDOUS VASTE, LIQUID (BRM FLUID) <br />343 <br />Rif <br />3. <br />4. <br />14. Special Handling In struc(ions and Additional Information <br />EMERGENCY CONTACT : CNEMTREC 1-800-424-9300 NAERGO 9BI 171 PROFILE 9B1 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately describ oper shipping name, and are classified, packaged, <br />marked and latiefed/placardiid, and are in aft respects in proper condition for transport according to applicable intemalionaland d shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknoyAedgment of Consent. <br />I certify that the waste minimization1tatement identified in 40 CFR 262.20) (if I am a large quarility generator) of (b) (if 4 a <br />Tefleraters/Offeror's Pri =ed d e Signature Month Day Year <br />7k <br />-j <br />P-- <br />16. tnternallonal Shipments <br />olmporttou'S. UN't from' U.S. Port of entrylexil: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment Df Receipt of Materials <br />ce <br />Tfanspo Pdriled/Typed N Signature Month Day Year <br />r� <br />Transporter 2 Ponled/Typed Name t-TSIV -ure, Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity Type Resklue PartiarRejection Ll Full Rejection <br />Manifest Reference Number: <br />l8b, Alternate Facility (or Generator) U.S. EPA ID Number <br />U- <br />Facilitys Phone: <br />6) <br />18c, Signature of Alternate Facility (Gf Generator) <br />Year <br />19. Hazardous Waste Report Management "ethod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />20. Designated Facility Owner or Operator: Certification of receipt Of I)Mlfdous materials covered by the manifest except as noted in Item 18a <br />Piinleclfrypecl Name Signature lAnth—Day ear <br />EPA Form omo-22 (R: 3-05) Previous eclittions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />- <br />