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Please print or type. Form Approved . OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS ' , Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST (. :,¢t.):4i� (J $ 94 i' .� � F , : yt, (,,i '�,., t ;., f <i i v d a� ti� FLE <br /> 5, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> Lodi 'Auylat HOSPAal Weal !. di1A0110thOHiia �itnt0 1 S � <br /> R� AX30 993 LMer 'SalcrsmspetTth i IT <br /> Lodi , CA 95241 Lodi , CA 65242 <br /> yt � x <br /> Generator's Phone: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> ',t $ Ei:• �:i4tira ittFtt:rlt +t J f; f�icrtFs ? '�:� `> ); la ( . 0 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> Wall) ins TectnflcjA 4ioluilims LLC <br /> 1704 WIFirst St <br /> Piwn 3o , x A 91702 <br /> Facility's Phone: 6261134-b117 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WI.IVOI. <br /> 1 ' UN 2811 Waste 'e oxic s;aft , atgennirt , 111400S4 {1vt-i:n!% 063, G. 1 <br /> o <br /> a <br /> z 2. <br /> LU <br /> c7 <br /> 3. <br /> 4. <br /> 14 . Special Handling Instructions <br /> isn <br /> and Additional Information Ma epk 1110212 <br /> I ) a144,1flag E, R( r15 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping 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 regulations. If export shipment and I am the Pdmary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if [ am a small quantity generator) is true. <br /> Generalor'slOfferor's Pdnted/Typed Name Signature Month Day Year <br /> r <br /> 16' International Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Port of enhylexil: <br /> ? Transporter signature (for exports only): Dale leaving U.S.: <br /> iX 17. TransporterAcknowledgment of Receiptof Materials <br /> LLJ <br /> Transporter 1 Printedfryped Name /] t Signature Month Day Year <br /> Transporter 2 Prinled(ryped Namef Signature Month Day Year <br /> F- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ quantity El Type ❑ ResidueJ El Full Rejection <br /> Pallial Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> ►a+. Facilitys Phone: <br /> LU 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> N19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . 2. 3. 4 . <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prinled/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />