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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 012285179 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) - <br /> FOLB LABEL AT OOTTEO <br /> Advanced Industrial Coatings LIRE. AFFIX TO RIGIiI <br /> 950 Industrial Dr SIDE OF HAZARDOUS <br /> Stockton, CA 95206 NATEBIAL BILLS 30 THAT <br /> Generators Phone, TAB STICKS OUT, <br /> 6.Transporter 1 Company Name U.S-EPA ID Number oast+Ono u001111L s .0 <br /> Advanced Chemical Transport Inc./DBA ACTENVIRO CAR000070540 <br /> 7.Transporter 2 Company NameU S.EPA ID Number <br /> MnV 'T1L A .3C-CV,C <br /> I CAAOGb 7 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Advanced Chemical Treatment <br /> 6133 Edith Blvd NE NMD002208627 <br /> Albuquerque, NM 87107 <br /> Facility's Phone: 505-349-5 <br /> Ra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> PM and Packing Group(if ani No. Type Quantity lNt.lVol <br /> 1 UN 1263, Waste Paint related material 3,PG11 2CP 212 D001 F <br /> ox <br /> W <br /> Z 2. <br /> LU <br /> 3, <br /> 4 <br /> I <br /> 14,Special Handling Instructions and Additional Information Project Num er 173827 Document#. D20841� <br /> 1)E RG#128-1 AC M112 Apo- <br /> 15, GENERATOR'SlOFFEROR'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 EPA Acknowledgment of Gonsent. <br /> I certify that the waste minimizalkon statement identifEed in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slDfferoes Printed Typed Name Signature Month ay Year <br /> l 1 <br /> i <br /> 1E.International Shipments <br /> 1-1Import to U.S. ❑Export from U.S. Port of er>F ylexil _ <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> UA <br /> Transporter 1 Prini.yped Name Signature r Month Yqar <br /> 0 <br /> a <br /> ansport r,n e T: ped Name Signature Month D r <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Relection Full Rejection <br /> ection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) S.EPA iD Number <br /> V <br /> LL Facility's Phone. <br /> Month Day Year <br /> w 18c.Signature of Altemate Facility(or Generator) <br /> a <br /> Z <br /> 19-Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recyciing systems) <br /> UJ 1' 2 3, 4, <br /> 20.Design Facility OWner or Operator Certification of receipt of hazardous materials covered by the manifest except as ryw in Item 18a <br /> Prin d(T Name Signature h D <br /> EPA Form 8700-22(Rev. -17) Previous editions are obsalefe. QESIGNA 0 EPA's e-MANIFEST 5Y5TE10 <br />