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Please print or type. Form Approved, OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . GeneratorlDNumber 2. Pagetof 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST C A L D 0 0 4 0 5 5 A 1 019 515101 JJ 5. GeAlKWIM '' UKsSERVICE3" Generators Site Address (if different than mailing address) 7679 LONGE STREET SkMCKTON CA 95206 Generator's Phone: 2 0 9 2 3 4 " T"'OH ISMO INDUSTRIAL SERVICES U.56116D Rmbr D 2 6 0 5 4 8 7. Transporter 2 Company Name - U.S. EPA IID Number 8, De (e�df9IW1gAVM1ssINC- K€`iTLEMAN HILLS U.S. EPA ID Number 35251 OLD SKYLINE ROAD KETTLEMAN CITY CA 93239 C A T 0 0 0 6 4 6 1 1 7 Facility's Phone: 559 3156m9711 9a 91b. U.S. OOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11, Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity WLIVOL 491 0 0 1 CM 00015 Y z z. w ce 3. 4. 4. SpikIMbo"s(w tnnd�ione .Wm R 12 :x - 1510- 010- 50001 JOEW o ff i . GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this coilidglarrent are fully and accurately describe above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in properwnQition for transport according to applicable internationaland national governmental regulations. If export shipment and l am the Primary Exporter, I cergly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (itI am a small quantity general r) Is true. Generatoesl�frerofsP nled/rype t Signato Month Day Year , 16. International Shipments ❑ import to U.S. ❑ Export from U.S. Pod of enkylexiC z Transporiersignature (for exports only): Date leaving U,S.: O' 17. Transporter Acknowledgment of Receipt of Materials Trans oder 1 Pontad Na Signature Month Day Year zrant der2Parle yped Name Signature Month Day Year h 18. Discrepancy 78a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: l8b. Alternate Facility (or Generator) U.S. EPA ID Number J V ' rat Facility's Phone: w 18c. Signature ofAltemate Factity (Or Generator) Month Day Year 3 z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 4. 1 � 20. Designated Facility Owner or Operator. Cediricagon of receipt of hazardous materials covered by the manifest except as noted in Item Ills Poned/Typed Name Signature Month D l ' V111 �O( KI EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TD EPA's e•MANIFEST SYSTEM