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317779 Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) 4 tit t� 5 14.72. 1093 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. , j DESIGNATED FACILITY T7ESTINATION STATE (IF REQUIRED) �,f 10804.1788 UNIFORM HAZARDOUS 1. Generator ID Number 167732 2. Psg_e.W 3. Emergency Response Phone ( 800) 4244-930@ --'� q T 4. Manifest Tracking Number DAT 0000 12020 A WASTE MANIFEST I.. I 5. Generator's Name and Mailing Address Generates Site Address oS�f�d�ifferent than mailing address) Fedex Frelght FEDE% FREIGHT (S!R) 4528 SOUTH HIGHWAY 99 FRONTAGE ROAD 4521 SOUTH HIGHMAY 99 FRONTAGE ROAD STOCRTON CA 95215 (289)466-2127 STOCSTOM CA 95215 (289)466-2127 ' Generator's Phone: 6. Transputer 1 Can Name U.S. EPA ID Number 21st Y 1TAL MAMA OF ,.LLC CAR000164012 7 s rter 2 amet U.S. PAID Number ler 8 D Fag)Ityya 11? ss LLC DBA PSC ENVIRONMENTAL SERVICES U.S. EPA ID Number '11855,MHITE RBOC%'ROAD' RANCHO CORl109A, CA 95742 (916) 351-1988 C'AD980884183 . Faalitys Phone:' ga_ 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 Wtivol. ar 1' fig,—ICU „HAJABOUS, CASTE LIQUID,. (CHLORINE. FRSE. BLEACH) '. '� 561 • Lill P a LU 2. UM1263 TASTE FAINT RELATED MATERIAL 3 PGII RQ(D111) Dell 3. 4. 14. Special Handling Instructions and Aldi Information ( Mr5 , ( V (1)'FEFNONHABLIQ=88 - FRO# 2/89573651 - NOV) FEFMPBM-82 - ERG(128),;FROt.1968533195 - VF �. 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationai and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if i am a large quantity generator) or (b) (d I am a small quantity generator 's true. Generatoes/Offeroes Pdnted/fyped Nam Signature Month Day Year _ ke'frVQ/ /t (/f� —1 I- 16. InternationalS ipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials CC Transporter 1 Printed/Typed Name Signature Month Day Year O CL _r Transporter 2pPrinted/1'yped Name Signature _ Month Day Year _ % 6`i4 IV � ATI -4-e— Qy - -/ I Z 18. Discrepancy 18a. Discrepancy Indication Space quantity ❑ Type ❑Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Altemate Facility (or Generator) U.S. EPA ID Number J V u. Facilftys Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. jqj 2. k 14-L T. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a Printedfryped Name signatureL'4-- Month Day Year f�1cl � 1 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. , j DESIGNATED FACILITY T7ESTINATION STATE (IF REQUIRED) �,f 10804.1788