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r: <br />Please print or hw. (Form designed for use on ergo 02 -pitch) tv ewritec) <br />• <br />Form ADDmved. OMB No. 20500039 <br />EPA Form 8700-22 (Rev. 3-05) Previous edtions are obsdetQ. r r Z Shcd- fti FAOAL)TY TO DESTINATION STATE ()F REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator 1D Number <br />2. Page 1 of <br />3. GTogerwy Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />CALOOtlM21 <br />1 <br />1. w78Sw= <br />008826994 FLE <br />5. Getne�ators Name and Mating Address Generators Site Address (d different than ma feq address) <br />515'1 S ARP TT'WA ' <br />Stockton, CA 96M <br />Generators poie:9162089664 <br />0. Transporler I Comany erneI <br />Adttertced Ttanaport Inc. <br />U.S. EPA ID Numbe <br />CA 7WO <br />7. Transporter 2 Com,%any Nam* <br />U.S. EPA ID Number <br />8 4nated Facility! Name and Site Address <br />U. S. EPA 10 Number <br />PO BOX t�99.11 Il n 6 Bee ty nc <br />Mti" L11000D <br />Fadatys Phone: n56 <br />9a. <br />9b. U.S. DOT Description (mdudng Proper Std Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Vftte Codes <br />No. <br />Type <br />HM <br />and Padding Group (d am)) <br />Quanfity <br />WUUot. <br />o <br />y� <br />1 <br />N O.S. (A9te�s, C12 24 CNoroj, 9. PG � • � <br />/331 <br />.`f..h <br />CF <br />P <br />Lu <br />2 <br />W <br />I <br />3. <br />4 <br />i <br />14. Spedal Handling Iru rix ons and Adgiornel Information <br />Pmjectt <br />79161 ent :IM04 <br />IPM 0M31510.11N2wAv(A - Cy's <br />15. GENERATGR'SIOFFEROR'S CERTIFICATION: I hereby declare that the Contents of this corsigrime a are fury and aaxxately described above by toe proper shipping name, and are dassrRed, packaged, <br />marked and labeledfplacarded, and are in all respects in proper ca0on for transport aocordng to applicable international and national govemmerdal regulalions. H wW shipment and t am Oke Primary <br />Exporter, l certify Oat the cor4ants of Onis oasignmant conform to the terms of the attached MAdmowiedgment of Consent. <br />i cw* Oat is waste renin ince stanrtnent klenl7ied in 40 CFR .27(a) (t i am a lege quantity generates) b) (d i sm a small quwft generator) is we. <br />'st s PnntedfTyped Name <br />ear <br />� <br />WIem , <br />nport ro U.S. LJ Export from U.S. Pod of ww* <br />Trans 1ure fes exports oxd : Date leave U.S.: <br />eeDC <br />17.Transporter A*vwledgmentof RVW of Materials <br />,� <br />ire er yed hrarhe na <br />Month Da,ear <br />dQnAo� <br />w <br />I 11 <br />Z6 <br />A <br />A <br />ra0spodor 2 P ' edfTyped NanaSignature' <br />Month ear <br />ill. Discrepancy <br />18a. Discrepancy ndicatien Space QLMF* ❑ Type ❑ Residue <br />IJ Partial R*dton ❑Full mectah <br />Manifest Rderenoe Number. <br />18b. Alternate Fad ly (or Generator) <br />U.S. EPA ID Number <br />V <br />LL <br />F s Phare: <br />Q <br />Z <br />18c. Signature of Akemafe Facility (or Generator) <br />Morw1h Day Year <br />S2 <br />19. Hazardous ante Report Management Method Codes (i.e, codas for hazardous waste treatmank d"l, and recycling systems) <br />-T- <br />G <br />1 <br />2. <br />3, <br />.20.1) <br />20. 1)skprnted Valy Owner or ckemtar: Certificarm of receipt of bazar covered by Oho marded except as noted in Item 18e <br />Prmtedffyped Name <br />SignaturerI <br />ar <br />Day YeJ_ <br />` <br />1A —7- <br />in <br />j I I I <br />/�Ji 1 <br />4 <br />EPA Form 8700-22 (Rev. 3-05) Previous edtions are obsdetQ. r r Z Shcd- fti FAOAL)TY TO DESTINATION STATE ()F REQUIRED) <br />