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Please print or type.(Farm designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL 000 358 973 1 510-541-2128 011252571 FLE ! 5.qy pttp�Name and Mailing Address Generator's Site Address(if different than mailing address) IU4U N mason Ave :+i�y Ie a�aiy ute� Upland,CA 91780-2167 Tracy,CA 95304 Generator's Phone: 510-224-8922 s6rMns§ er, nvironmernalSolu�ons US. Pa N )er48010 irKoduesQiiagsivJCe ItviS1�P��U�e2 742 8 e}LJrtojtr ity Name and Site Aodress U S.EPA ID Number Highway 95,11 miles south of Beatty Beatty,W89003 Facility's Phone: 8002392943 NVT 330010000 _ ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit HM and Packing Gfoug(it any)) 13 Waste Codes ' 1`rt^1c�. � N 1993,Waste FPamnub{!s Liquid,N.O.S.,3, PG Hi (Gas & = TIGr Quanray- - :00101 4U 'n —w �� 213 } Z 2.LU r 4. yy' I OtAm In~I MAAtiona!Information Pro19e* 9b.1 0?0zg8J90•Q EMERGENCY CONTACT.EFF RHODES ENVIRONMENTAL HEALTH Mp:pAPT�AIFNIT 15. GENERATOR'SIDFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckrnowledgment of Consent. t I certify that,the waste minimization statement identified in 40 CFR 262.27(3)(if!am a!arge qua"gpreraVTt%(b)(4I am a small quantity generator)is true. j sign aiUr- - Monm Uayy year Z 16.International Shi eats Z ❑Import to U.S. ❑Export U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedliyped Name Signature Month D? )ear z Transporter 2 Pr nted Name Signature Month �Day Year f 9 �' ,0 IZ7- 18.Discrepan 18a.Discrepancy Indication Space Ouanuty El Type El Residue ElPartial Rejection Full Rejection _ Manifest Raterenre Numtwr t 8b.Alternate Facii:ry for Generator) U.S.EPA ID Number J U Q �+- Facility's Phone: uu 18c.Signature ofMemate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) w 4 o' 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)