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ATTACHMENT C <br /> Please print or type. Farm Approved.OW No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generetor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mackjpg urrtperr <br /> WASTE MANIFEST CALM012MBO 1 888-7&5-7225 fV� 1! CLJt U(v� FLE <br /> 5 Generators Name and Mailing Address Gonerators Site Address(if different than mailing address) <br /> Mari Unified Si info!Distili (East Llnion Rgh) <br /> 1700 N UT1it)n Road <br /> Malkeca, CA 06W <br /> Generatoi's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AAwrcad C[milini Tr"ptart kx JDBA ACTEtNA0 GARQ(](3D70,5A0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address V.S.EPA 10 Number <br /> Adwm!id C}'euro:. Trcatmanl <br /> 6133 Edith Bhd t, Pli D00220MV7 <br /> Atbl.tquer", Nita 87107 <br /> Fadlii Phi 5ffilui- <br /> as 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,10 Number, 10.Cortlakners 11.Total 12.Unit 13.Waste Codes <br /> UM and Packing Group(if any)) NO. Type Quantity Wooi. <br /> 1•U1N:32B7,Waste Tomic ,knoi i�C,wit i.(Potbh�iillir OFFs 651 L-3 <br /> ao x -rtdncyanate),6.1 ,PrA <br /> w <br /> z 2 <br /> w <br /> 0 <br /> 3 <br /> 4. <br /> f <br /> 14.Special Handling Instructions and Addiliorat Information PMWA NUnber 1915gti D t 1[ii f_rr '( <br /> i)EIRili AM3778 MAA-.01 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this oonsf nmenl are fully and accurately described above by the proper shipping name,and are ctessifed,packaged, <br /> marked and Iabeled!placarded,and are in all respects in proper condition for transport according to applicable inlemafionsland national governmental regulations.If export shipment and tam Ute Primary <br /> Exporter,I certrfy that the contents M this consignment conform to the lerms of the attached EPA Acknowledgment of Consent. <br /> I certify trial the waste minimization statement klenlifled in 40 CFR 252.27(a)(If I am a large quantity gonerabr)or(b)(ifI am a smart quantity generator)is true. <br /> SeneratoeafOffemrs PrinledlTyped Name r1 m Signature I Month Day _ Ye <br /> � 18.Enlemalional Shipments - <br /> ❑Import la U.S. ❑EVW from Ui Por1 of el"lexlt: <br /> Transporter slgna ure(for exports only): Dale IaavYtg Li <br /> W 11,TranspomterAcknowledgmenlofReceiplofMaledalsLU <br /> /J' <br /> Tff rPaigVeplTypedNeme �' ��� G Stinlh Year <br /> r ?1T! �jr_ [S 1 / <br /> W Transporter 2 PdntedlT Narne ✓ x= <br /> YP� Signature Month Day Year <br /> t8.C screpanCy <br /> 18a Discrepaccy Indication Space ❑Ottani <br /> ty ❑Type ❑Residue ❑Partial ReJfctim>n ❑FuN Rejec6arl <br /> Manifest Reference Number. <br /> 1 Bb.Altamate Fadliry(or Generator) U.S.EPA ID Number <br /> J <br /> Q <br /> Facility's Phone: <br /> LLI 1$c.Slgnalure of Alternate Fecltly(or Generator) Month Oay Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and reeyding systems) <br /> uJ G 1. 2. <br /> 20,Designated Facility Owner or Operator:Celificabo n of receipt of hazardous maleri&covered by the manifest except as tided In Item 18a <br /> Print yped Name Signature Day <br /> EPA Form 8700.22(Rev.12-17) Previous edilioas are obsolete. GENERATOR'S INITIAL COPY <br />