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/Z0 <br /> Please print or type.(Form"designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone n' roc ng umber <br /> WASTE MANIFEST CAL D o 4 S 1 JJ <br /> 5.Generators Name and MciTmg Address Generator's Site Address(it different than mailing address) <br /> 12�_ 9W THOMTON FM <br /> E ST CA 94M8 STOCKTON CA sum <br /> Generabes e: D <br /> 1.Transporter 1 Company Name U.S.EPA ID Number <br /> 8920 i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Na09 8e"1373 0 <br /> 8.\Designated Facility Name and Site Address U.S.EPA ID Number <br /> AR 7mis <br /> Facitilys Done: <br /> A C �i057 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazed Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Packing Grasp(d any)) No. Type Quantity wtAfol. 13.Waste Codes <br /> 1' <br /> ® % F EL ,4.1,43 t , S <br /> Z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling InsWdmns ark I <br /> tJ SEFOO.M. 133,1*EMW.OJ65117-EC8*COkMMCTM <br /> 4 NANIO OF9 <br /> BUTO EWOWSM'WEAR PROM PPI! <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, <br /> marked and labeledtplacarded,and are in all respects in proper condition for transport according to applicable Intonational 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 EPAAdmowledgmerd of Consent <br /> certify that the waste minimization statement identified d kn 40 CFR 26227(a)(d I am a large duan g or(b)(If I am a small quantity genera"is true. <br /> trx slOffeors Prkdedf yped Name a V MZ Day Year <br /> C ^A 4 <br /> J 16.International Shipments <br /> ti F ❑Impat to U.S. ❑Export from U.S. Pat of entryfe)o <br /> M Transporter signature(for exports only): Data leaving U.S.: <br /> IX 17.TransporterAdmowledgment of Receipt of Materials <br /> Transporter 1 CILPrintedCTyp Morntin Day Year <br /> - _ - { . <br /> Transporter 2 y Narne �. re Month Day Year <br /> ( _ — - 1 <br /> ��! <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Num <br /> V <br /> Facillys Pune: <br /> W c hire of F a mlor) m Madh Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment ,and recycling systems) <br /> ® 1. 1 1 / <br /> O2. 3 4. <br /> H-LXO <br /> 20.Designated Facility +(wner or Operator Certiticaton of receipt of hazardous Mals covered by the manifest excjW as rated in Iter I8 <br /> , <br /> e drre ear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />