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Please print or.type <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number. Z Page 1.of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C� 209-234-1600JJK <br /> 5.Generators UJN Name end:MailingAddress Generator's Site Address(if different than mailing address) <br /> I�C1l.l.fNOFcY��1vCae' <br /> 17aO INDUSTRIAL€]r. <br /> STOCKTON,CA 9M <br /> Generator's Phone; 209-254-16M <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> Ge"ge W.Corm`,Irl$. <br /> CA <br /> 4D5I147019 <br /> 7Vanyorter 2 Company Name U.S.EPq ID Numher <br /> CM <br /> U.S.EPA ID Number <br /> 162D E. 19RUM AGe LR <br /> BAKERS IEEE}_CA 93.W <br /> Facility's Phone;x661-=- <br /> 9a 9b-U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers -Total 12 Unit <br /> HM and Packng Group(if any)) fi <br /> No Type Quantity, W1.NcL 13.Waste Codes <br /> SOUD <br /> w <br /> Z 2. <br /> 3 <br /> 4. <br /> 14 Speciaf Handling Instructions and Additional Information <br /> ERG 0171 O,c `� �2 1 PROFILE# <br /> WEAR GLOVES <br /> 15 `Git-NERATOWS10FFEROR'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, o <br /> matked and Iabeledlplacarded,and are in all respects m proper condition for transport according to applicable ipternatidnaland 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 EPAAcknowledgment 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 /> rnerr'slOfferors,ites//Typed Name Signature <br /> Month DayrRA <br /> Year. <br /> j 16 International Shipments <br /> 1 . <br /> r— ❑Import to U.S. ❑Export from U.S. Port of entrylexil: <br /> -3 Transporter signature(for exports only). <br /> Da leaving U.S.: <br /> W 17 TransporterAcknowledgment Df Receipt of Materials <br /> 1ranjkPL8Qqd Name Signature <br /> Q Mcirdlv, Day Year <br /> Z Trans rt r 2 Prin yped Name Signature r G/f <br /> ni t-%% Month Day Year <br /> 18.Discrepancy i <br /> 18a Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑ <br /> Full Rejection <br /> 18b.Aiternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA fD Number <br /> LL facility's Phone <br /> Hc tgma ure ofAItemste Faidi ty(or Generator) <br /> Month bay Year <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. <br /> 4. <br /> o20 nt d!T evgn to Name Owner or Operator Cerlification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P _ . <br /> / Signature Month bay Year <br /> EPA Form 8700-22(Rev 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />