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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 Phone4.Manifest Tracking Number �( <br /> WASTE MANIFEST JJ 1\ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> �_rRNTCN4 <br /> aG KV 401 A.TTNd !fJY KA.CHA.D"14 <br /> QST SACRAMetIT0.CA "91 <br /> Generator's Phone: ,,�-,;- <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressU.S.EPA ID Number <br /> 515 SWH RR/ER RD. <br /> 4VE:3T SACRA.MENT0,CA gar <br /> Facility's Phone: <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 wt./Vol. <br /> a, 1• JuN Fui+K.H?i;ARj3{33Uti IVA&rr- SOUR (tni, GEEssef�l <br /> O <br /> Z 2. <br /> W <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ,r3-1 W U� LEN F-Flkf 071 J?f- 5,: co .3 I'� <br /> R. CONTTR-4L70R R.AMOS ENVIRONMENTAL <br /> HAII XERS SHOULD ME TRAMMED AJ40 USE APPRCJVF°D PP(t <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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)(if I am a small quantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> IL <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Full <br /> El Partial Rejection 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 /> Ll 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 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 /> rnted/!ped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />