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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 i. GeneretorlD Number 2, Page off 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL f� !a x �€ iP 1 { 89f�'j ^s ctl— a3Q1�3 011178631 JJ <br /> 5. Generators Name and Mailing Address - Generators SiteAddress (it difierentman mailing address) <br /> AJRMaI RK <br /> 7@791 S. LONGE ST. <br /> STOCCUON C:A 95200 <br /> Generators Phone: ( 209) 2134' i 7f <br /> B. Tr sport 1Company Name c U.S, EPA W2o4 ; 11 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address US, EPA ID Number <br /> CHEfvilCAI t[kASTE MAI%4AGEMEP4T, INC. <br /> 36253 OLD SKYLINE ROAD C A E ail 0 6 .4 0 1 1 7 <br /> KETTLE10AN4 C-1TV CA 0239 <br /> Facilites Phone: ( MWl1) 380- ill i l <br /> as. 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. Typo Quantity wt./Vol. <br /> 1• NON RCRAHA ARDOUSV%AS1E SOLD <br /> O <br /> 9 <br /> 3. F ; <br /> 4. <br /> 14. Special Handling Instructions andAddiBonai Information08852 <br /> CHEF TRECCONTPACTOCN2? 117 � f� 7 • <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplacarded, 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 cerfify that the contents of this consignment conform to the tens of the attached EPAAcknowledgmentof Consent. ' <br /> I certify that the waste minimization statement identified in 40 CFR 202.27(a) (if i am a large quantity generator) orb) (if I am a small quantity generator) Is e. <br /> Genemtars/Offerors Pdntedrf ed Nae �� Signature V n Month Day Year <br /> sr 16. International Shipments <br /> F- ❑ Impart to U.S, - ❑ Export from U.S. Port of enbylexil: . <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> W 17, TranspoacrAcknowledgmentof Receipt of Materials <br /> Transp rt 1 into I ype Nam Slgn Month Day Year <br /> Q ffi <br /> ? <br /> aTransporter 2 Pdnte yped Nae Signator enlh Day Year <br /> ti <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Spars ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 186. Alternate Facility (or Generator) U.S. EPAID Number . <br /> V ' <br /> r¢+. Faclllty's Phone: <br /> 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> H <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal; and recycling systems) <br /> 14�i :Z17 12. 3. 4. <br /> V . <br /> 20. Designated Facili 0vmer Opemlor. Certification of receipt of ardous materials covered by the manifest except as ncted.in hemi <br /> Pdntedrryped Name Signature Month Day <br /> EPA Form 8700-22 (Rev. 3-05) Previous a ions are obsolete. DESIGNATED FAClhZVP4Td DESTINATION STATS 6F 146QUIRED) <br />