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J-OZ� # v 190 3 3 S-1 \331-1 79 Generator acknowledges that no material change has occurred either in the characteristics or In the process generatingFiorhelppratenal ni..,...., ..a„� ,,. �.,..., al ov . OMB No. 2050-0039 EPA Form 8700-22 (Rev. 12.17] Prey obs editions are obsolete. DESIGN TEb FACILITY TO EPA's e -MANIFEST SYSTEM Clean Harbors has the appropriate permtts for and will accept the waste the generator Is shipping. WSC' ?OD f ?91Fi?q-004 PPW UNIFORM HAZARDOUS1. Generator ie Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracgmber 014198830 F L E WASTE MANIFEST C A L 0 0 0 4 2 0 0 2:3 (800) 483-3718 S. Generator's Name and Mailing Address Generator's Site Address {if different than mailing address) Stockton Delta Resort, LLC 14900 W Highway 12 SAME Lodi. CA 95242 Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number Clean Harbors Environmental Services, i;ntti 7. Transporter 2 Company Nam U.S. EPA ID Number Ata �fi C o F o3 �� x _S� /YI t- -D B. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors Environmental Services- Inc. N r n 7 0 a a - 2-3 3 it L v u L ` Ir -%J If� 2247 South Hiiih'f trrav 71 FK',i t NE S9i45 acl C206M 22169 4 012 ya 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class,ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 1 UNi325. WASTE FLAMMABLE SOLIDS, ORGANIC. N.O.S., 0001 J D019 35 F- X (ABSORBENT BOOM CONTAMINATED WITH GAS AND OIL1. 4.1.PG III �i SdU z 2. LU ah i 3. 4. 14. Special Handling instructions and Additional Information 1 _CN:L9B5352 ERG#133 contract retained bV Qenerator corners agency 15. GENERATOR'S10FFER0FVS R F AIN: y adore conn is %ignmen are and ecru iY scn a ve a proper s ippmg name, a ora asci p aged, marked and labeledfplacarded, and are in all respects in proper condition for transport according to applicable intemalionaland national governmental regulations. Itexport shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identltied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator)istrue. Signatu� Month� Year Gen torsl(Xterors Pdn n pe l h '� . _ liar) 1. e F 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: ix LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PdntedfTyped Name Signature Month Day Year R41rZ t6l��l 119 120 Z Tra r 2 Printed/Typed Name Day Year !Znatu-�Month 1 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection FuE Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J_ V LL Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year a z 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2.3. 4. H040 26. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped NameSignature Month Day ear �� EPA Form 8700-22 (Rev. 12.17] Prey obs editions are obsolete. DESIGN TEb FACILITY TO EPA's e -MANIFEST SYSTEM Clean Harbors has the appropriate permtts for and will accept the waste the generator Is shipping. WSC' ?OD f ?91Fi?q-004 PPW