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Please print or type. (Form designed for nation elite (12-pitch) typewriter.) . Form Approved.-OMB No, 2050-01339 <br /> UNIFORM HAZARObUS 1, Generator ID Number , . ; 2. Page 1 of 3. Emergency Response Phone ; 4: Manliest Tracking Number ` <br /> WASTE MANOST CAL 0 0 4 a . 5 5. ' � ., -r: 0.11180921 . JJK <br /> 6. Genereto 's Neal and MeilingAddress Generato(s Site Address ('Rdifierent titan mailing address) _ V, " <br /> ARA(AARWfi <br /> 7679 S, &Nd E ST. <br /> STOCK,ON CA €16200 <br /> Generator's Phone: <br /> 6. Transporter 1 Company Name ry ,- F U.S. EPA ID Numbeear <br /> 7. Tmnspoder2 Compainy Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S, EPA ID Number <br /> C,HEAd).CA.L \AeA9E MANAGEMENT, INC. <br /> 35261 OLD SKYLINE k ROAD CAT 0 0 0 e6 4 6 1 1 7 <br /> K i; L EMAN CITY CA 9823; <br /> Facilli es Phone: f 659) 366- 9711 <br /> ga. 9b:U.S. DOT Description (Including Proper Shipping Name, Heard Clads, ID Number, 10, Containers 11, Total 12. Unit 13. Waste Codes <br /> HM and Packing Group(If any)) No. Type quantity WL/Val. ^p <br /> ® 1 NON RCRA HAZARDOUS WASTE SOLID r � •, �r� .I [� \ p.�. - <br /> ad CA608852 IV <br /> z 2. <br /> w <br /> 0 <br /> 4. <br /> 14. Special Handling Instructions and Additional Information ` :': a <br /> .1 , _:,�;6r08862 CHEAITREL CONTRACT O� C' I`51 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by thb proper shipping name, and are classified, packaged, <br /> marked and labeledlplacerded, and am in all respects in proper condition for transport accordingio applicable International )I national governmental01ll tions, If expert shipment and lean the Primary <br /> Exporter, Icertify that the contents of this consignmentconform to the terms of the attached EPAAcknovAedgment of Consent' <br /> Icertify that the mine minimization statement Identified In 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (if I am a small quantity generAf ' f ' . <br /> Ge lot's R rsP fe dName Sign' e r I Month Day Year <br /> --r 16. international Shipments " <br /> F- import to U.S. ❑ Expbrtfrom U.S. Pod ofentrylexit: f==� <br /> Transportersignature (for exports only): Date leaving U.S.: ' <br /> o-' 17:Transporter Acknowledgment of Receipt of MaterialsY '+ <br /> w <br /> Tr,"sem`11`Fdtiiedfryp dNalne 'r 'x SignaWre Month Day Year <br /> � i c �ec�e <br /> GO <br /> Tmnspomer2 Printedrryped Name Signatur Month Day Year' <br /> .Ip <br /> 18. Discrepancy I�( <br /> LJ ,4 <br /> I 18a. Discrepancy indication Space ❑ Quantity _ Typer Residue ❑ Partial ReJecfion ❑ FulfRejection ;v . ' t <br /> ManifestAm ce Number: <br /> 18b. Altemate Facillty (or Generator) ' , _ ,J fikra`; y,+_n, U.S. EPA ID Number o <br /> " 3 <br /> Facility's Phone: <br /> w 180. Signature ofAlter nate Facility (or Generator) .�; Month Day Year <br /> Q { <br /> y 19. Hazardous Waste Report <br /> tMMManagement Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> � 1 2 3. 4. . . y <br /> a 20. Designated Facility Ovmer or Operator: Codification of eceipt ofha Nous materials covered boo manifest except as noted In It 18a <br /> Printedfryped Name _ Signature c' . ^ Mo ; Day Year <br /> Sr ; <br /> EPAForm 8700-22 (Rev. 3-051 Previou ditions are obsolete. sV��@PftN��C�Pa ® , B s'tq.q[y i7��5dp{igf��p®R9 g�'p`PL l9� RmUIRED1 <br />