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DISC. 042SS - 0693 <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 one 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 9 012 3 1 (800)4249300 017468179 JJ K <br /> 5.Gene ratat'sRNaWd��i EWM UT027 Generators Site Address(d different than mailing address) <br /> 3077 E HAMMER LANE <br /> STOCKTON CA 95212 <br /> 209 955-3162 <br /> Generatofs Phone: <br /> s.Trans"4SBONVOONMENTAL SERVICES u.S.EPCAtDN 0618 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA IAD Number <br /> 8.Design�ted�8citijy Nijrrle aOgSite.Addre& U.S.EPA ID Number <br /> 55375 SOUTH BBOFYLLEOIAVVENUE <br /> LOS ANGELES CA 90058 CAD097030993 <br /> Facility's Phone: (323)277-1500 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> 1• NON-RCRA HAZARDOUS WASTE.SOLID(OILY SOLID,PAPER FITERS) 352 <br /> 0 <br /> DM P <br /> z 2. <br /> L <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information * w <br /> EMERGENCY CONTACT CHEMTREC 1-800-4249300 PROFILE#SBI:062217-01 S'OL OLID,PAPER FILTERS <br /> P500.00035689 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT ) ? yty'l 6"? <br /> 6 <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 EPA Acknowledgment 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)(•rfl am a small quantity generator)is true. <br /> GeneratorslOBgroes Printedfrypedpaqp Signature Month Day Year <br /> G/'�� P,-- Z <br /> 16.Intemational Shipman <br /> Z ❑Import to U.S. El Export fro S. ort o niry <br /> Transporter signature(f r exports only): D eavingk. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans iter 1 Printed/Typed Name Sign Month Day Year <br /> O <br /> a ��l�V <br /> N <br /> QTransporter 2 Printed/Typed Name gnature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 41 U1 1 2. F <br /> 4. <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 Day Year <br /> I 8 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obso ete. DESIGNATED FACUIVY TO DESTINATION STATE(IF REQUIRED) <br /> 12641.1765 <br />