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Please print or type. Form Approved, OMB No, 2050-0039 '.. <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Pagelof 3. Emergency Response Phone 4. Manifest Tracking Number q pp ppi�pp <br /> WASTE MANIFEST CAL 0 0 0 4 9 . ® g JI ® �J 1 p� <br /> " 'ON ofs NaNCdM 'f SERMES Generator's SiteAddress (if different than mailing address) <br /> 7679 LONGE STREET <br /> SMCKTO9 CA 95206 <br /> Generator's Phone: 2 . 0 9 2 3 4 0 1 0 6 <br /> 6. Transoder 1 Company Name .. U.S. EPA ID Number <br /> �NILIP VEST INDUSTRIAL SERIA CES C A R 0 0 0 2 0 0 R 4 D <br /> 7. Tramporter2 Company Name U.S. EPA ID Number '.. <br /> 8, Deslanat�d.Facl Site�dd6VVINO, KE�EMAINI FOLLS U.S. EPA ID Number <br /> 33522511 OLD SKYLINE LROAD <br /> KET1'LEMAN CITY CA 93239 <br /> Faciliys Phone: US711 CAT ® 0 0 0 4 0 1 1 7 ! <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Caries <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br /> I. I RCRA R IDS MSTE. 11) 491 <br /> O <br /> 0 A 1 0181 OW15 Y <br /> z z. <br /> w <br /> 3. <br /> 4. <br /> 14. 8SR , 1n�,'nsrum nar Ion�.$rsa tt 122- 1610- 0010—J000l <br /> °JPk�yajCM <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Unit 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 Interactions]and national governmental regulatlons. If export shipment and l 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 CFR262.27(a) (if I am a large quantity generator) or (b) (if] am a small quantity generator) Is We, <br /> Generatorsl0t[are2s Pr ted/Typ e + Signals youth Day Year '.. <br /> 7761 <br /> d tl <br /> 16. International Shipments '.. <br /> F- ❑ import to U.S. ❑ Exportfrom U.S. Portafenky/exiC <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> aC 17.TransporterAcknowiedgment of Re tofMaterials <br /> Transporter i Printed/Fyped Na Signaturepie! M n Day Year <br /> Pensioner 2 nnted7fyped ame Signature Month- - Day ear <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Partial Rejection El Rejection <br /> Manifest Reference Number: <br /> h 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> ua- Facility's Phone: <br /> w 18c. Signature ofAiternate Facility (or Generator) Month Day Year <br /> W19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1. 2. 3. 4. <br /> Gs- <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Ilam 18a <br /> Pdnyedf(yp dName Sign lure Month- Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's emMANIFEST SYSTEM <br />