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Form <br />lease print or type. Approved. OMB No, 2050-0039 <br />1. Generator ID Number 2. Pae 1 of 3. Emer enc Res onse Phone 4. Ma fe t Tr cki N er <br />UNIFORM HAZARDOUS 9 9 Y p r FSE <br />f <br />''i G <br />WASTE MANIFEST 141 C)4 95i 9; ' i3 78�7� 5 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Webei Winy <br />1 Winmiasrer Way <br />Lodi, CA 95440 <br />Generator's Phone:iiv 3r'S <br />6, Transporter 1 Company Name U.S. EPA Ib Number <br />Admiced Chemical Trans P1L.,/I: RA AC TEWIRO GAR000070540 <br />+ U.S. EPA ID Number <br />7. Transporter 2 Company Name RECEIVED <br />8. Facility Name and Site Address U.S. EPA ID Number <br />pDesignated <br />4 OCT��p eqa� � <br />l'RU�§rt ced i.. hm aa!'Treatment trJ i <br />6133 Edith SW E 4d E�4i e..� <br />AIbuqu€l&gt_te, W 87107 <br />Facility's Phone:fq Ui '. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, I) !,1)r` I�•I- ` <br />- ,1 <br />,Containers <br />11. Total <br />12. Unit <br />r <br />13. Waste Codes <br />ga <br />HM <br />and Packing Group (if any)) <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />O <br />Z <br />2, <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information Project Number 189999 Ctt.Y:'Urfteal #: 0228103 <br />11 At�l 3410 A3Ctrw <br />15. GENERATOR'S/OFFEROR'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 Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 I am a small quantity generator) is true. <br />Generator's/Offerors Printedffyped Name Signature -, Month Y Yea <br />j <br />WJ <br />16, International Shipments <br />Import to U.S. ❑ Export from U.S. Portof entry/exit: <br />El` <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />17 Transporter Acknowledgment of Receipt of Materials j f <br />WW <br />� <br />., <br />Transporter <br />{1 PJintedffype"}d Name Signature [! ,'� �*�+' ✓6 Month Day Year <br />C <br />a i�r✓"dSr� <br />(' 3{t.: t <br />z <br />Transporter 2 Printedfiyped Name Signature Month Day Year <br />t- <br />18. Discrepancy <br />18a, Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />W <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LIJ <br />2, <br />3, <br />4, <br />1. <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month DayYear <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />