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pr,aca mW nr tuna <br />Form Approved. OMS No. 2050-0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. Ut516NA I tU I-AI;ILI I T I U tt A"S e-MANII-tJ I JTJ I tM <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />012218831 FLE <br />WASTE MANIFEST <br />- ^^^�,r-�� -. <br />t-� ��� ^-�, <br />S. C-4maratoes Name and Mailing Address Generators Site Address fit different Dian mailing address) <br />acoba vi�s'il riedE ivSr il3 CfYi i'i' Global Materials <br />4831 Gera POEJ Rd I= North Broa"ay At <br />Lodi, CA -06215 2"tc7n, CA 9S21S- <br />Generators Phone: 121C;-@Wi <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Pulas Eivirunnit:netat SDlt )o 1 <br />7. Tr porter 2 Company Name U.S. EPA €D Number <br />Cort] <br />�► x n���cx��cx[a�c <br />S. Designated Facility Name and Sile Address U.S. EPA ID Number <br />US ECOLOGY NEVADA <br />ft 95. 11ties South of Beatty �r'"v' 3 mo i <br />Beatty, NV DD3 <br />Fadilty's Pone: 75-ar53-= — <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12• Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if arry)) <br />Quantity <br />Wt.Nol. <br />,yly'. _ stxi n c.S. <br />W <br />Z <br />— <br />1. <br />W <br />0 <br />3 <br />4. <br />14 Special Handlin tnslrvGiarts and Addilboal Informalion n, -. r •., ,. f n^r +r. n , <br />15. GENERATOR'81OFFEROR'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 labeledfplacarded, 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 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 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifl am a small quantity generator) is true. <br />Generator'slOf mes PrinledlTyped Na Sign re2 Month Day Year <br />2 19, <br />% intematio Ihipmedis <br />❑ Import to U.S. ❑ Export from U -S. Port of entrylexit: <br />F <br />? <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter I PrintedfTypeddNe Signature Month Day Year <br />y <br />Transp 2 PDl y d NMonth Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ® quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b, Alletnale Facility (or Generator) U.S. EPA ID Number <br />J <br />Fadllly's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />2 <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1,L <br />3. 2. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name t Signaler MonthDW -31 <br />Year14 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. Ut516NA I tU I-AI;ILI I T I U tt A"S e-MANII-tJ I JTJ I tM <br />