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II <br />262017 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />OF0V .0.342.0732 <br />1139898 <br />Form proved. OMB No, 2050-0039 <br />EPA Form 8700-22 (Rev: 3-b5) Previous editions are obsolete. Dk&GNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10730.2225 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />e 1 of <br />7- <br />1 3. Emergency Remise Phone <br />14. Man at ra n N be <br />73 JJK- <br />WASTE MANIFEST 167732 <br />x <br />( 800) 424-93001.( <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Fedex Freight FEDEK FREIGHT (STK) <br />4520 SOUTH HIGHWAY 99 FRONTAGE ROAD 4526 SOUTH HIGHWAY 99 FRONTAGE ROAD <br />GenaMOMM CA 95215 (269)466-2127 PTOCKTON CA 95215 (209)466-2127 <br />6. Transporter 1 Company Name U.S. EPA 10 Number <br />21st CENRW ENVIRONMENTAL MANAGEKM OF NEVADA, LLC C-AROW164012 <br />TrMFU.. EP I Number <br />8, Designated Facility Name and Site Address U.S. EPA ID Number <br />GENERAL ENVIRO TAL NGT, LLC DHA PSC KRVIRONWTAL SERVICES <br />11855 WHITE ROCK ROAD <br />Fedl s Phone:RANCHO CORDOOA CA 95742 916 351-8986. CAD980884183 <br />9s, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padding Group (If any)) <br />Quantity <br />Wt.Nol. <br />NOR RCRA HAZARDOUS WASTE LIQUID, LATEX PAINT <br />2� <br />,ccIxi <br />P <br />� <br />� Z <br />z <br />2. <br />LU <br />0 <br />3. <br />4. <br />14, Special Handling instructions and Additional information <br />(1) FUSLAM-06 - PRO# 2045288.314WEAR PROPER PPE <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this coni nrnent are idly 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 Primary <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) ('d I am a large quantity generator (b) ('dl am a s n nerator) is true. <br />Generator'sfOf toes Print Name SignaVej <br />/ MogM Dai year <br />Y <br />L�►%G� G(G- Q✓�/d <br />1 <br />(: <br />16.International-Shipments <br />❑ Import to U.S- El Export from U.S. Port of entrylexit <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />IX <br />17. Transporter Acknowledgment of Receipt of Materials <br />CL <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />a <br />6Ra C2/0 <br />Q <br />Transporter 22PPn' ted/Typed Name Signature .Month Day Year <br />nt <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejekd. <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />fJ <br />►ori. <br />Facility's Phone: <br />w <br />18c. Signatureof Aitemate Faetiity (or Genera) <br />Match Day Year <br />d <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />G <br />�1 L 1. (r <br />1 <br />2. <br />20. Designated Facility Owner or Operator. Certifica fi of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name <br />Signature A <br />Month D Y <br />EPA Form 8700-22 (Rev: 3-b5) Previous editions are obsolete. Dk&GNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10730.2225 <br />