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<br /> Please print or type.(Form designed for use on elite(I2-pitch)(ypewriter:) r ": Form Approved.OMB No.2050.0039
<br /> UNIFORM HAZARDOUS •.Generalor ID Number = -Page 1 of 3.Emergency Response Phone 4.M nifeat TracId Number
<br /> WASTE MANIFEST C A L O O(?2 9 4 4 3 s (��)424-9300 (�14 0K 3 4 7 4 JJ K
<br /> S.Genera1MT.t�t�"° �' ress en
<br /> :r;•+:i 1n:,; c c;,ly;gi.rest,Gerator's Sile Address(f different than mailing address)
<br /> i 5646 E.'HAMMER LN.
<br /> STOOKTON CA 9521.0
<br /> 20985,21-A,7fi0 : '>1,.,; �;1,, ;i,il .:L.:�,, •, - i!.., . :.,,.',, ,•, :,r� � i:i: ,� r
<br /> Generator's Phone:
<br /> s.TraA �3 � I� QNMFPSAI: 'nU.;8.,'E76Vbm2i&ua2.!17 ?-.03ci
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<br /> 7,Transporter 2 Company Name U.S.EPA ID Number
<br /> 8.Design I "' "" "'• "'"'" '' U.S.EPA ID Number
<br /> . 'I `I` oLOGIES LLC r,
<br /> 537 SOUTHBOYLEAVENUE
<br /> LOS ANGELES CA DW589 7
<br /> (32$)27.7-500 G A i�Q O 3 TJ 9,9
<br /> Facility's Phone: i' ".•i l r:}.. n In•,,
<br /> 9a 9b.U.S.DOT D10.,Containers ;.t 111,Totaloo;> 12 Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type QuantityWt,Nol.
<br /> n G it
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<br /> Z 2:CD
<br /> , . , :!a I Kltrly hi.:�1,�lI,� ,., 1 .Ji r .,...h.� J .,..iC. ...I .:•It;t�....
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<br /> 4.
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<br /> 14.Special Handting;lrfstruclions and Additional Information `
<br /> tMtt QENCY PORTACT;CHEMTREC 1-800.424-9300 NRERGO 981.:171 *PROFILE#981:AP19919¢OIt:Y_ROLIDS
<br /> A1120220383 x sf'PROPRtATl;PERSONAL PROTECTIVE EQUIPMENT
<br /> 15. GENERATOR:,SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this cohsignmenl are fully and accurately described above by the proper shipping name,end'are ctassilied;packaged,
<br /> marked and labeledlplacardad,and are In all respects in proper condition for transport accort*q to applicable international and national governmental regulations.If export shipment Md I am the Primary,
<br /> -Exporter,I certifythatthe contents of Ih)s consignment conform to the terms of the attached EPAAcknovdedgment of Consent
<br /> I certify that the waste minimization statement ldeni$e.d in 40 CFR 262.27(a)(if I am a large quantity generator)joF(b)'pf I am a small quantity generator)is true.
<br /> GederatorsfORerce.s Printed/Typed Name; Signalur� 1^ �. "Mjontthh1.j Day Year.
<br /> --j 16.:Intemational Shipments,
<br /> ❑Im*'to U.S. ❑Export tram U.S. Port entrylexit
<br /> Transporter,sgnalure(for exp'oI's only): Date leaving U.S;:
<br /> X 17'TransporteCAdmoMddgmenl of Receipt of ials Mater - ,
<br /> I-- nature Month Day '. Year
<br /> a T er.1 PrintadlTyped Na �9
<br /> z Transpoder2 PdntedfTyped Name —Signafure+M1 Month Day •. Year
<br /> Illi Disaepancy. .
<br /> 18a.Discrepancy indicalldri Space '+❑ quantity ❑Type: ❑Residua ❑Partial Rejection ❑Full Rejection
<br /> - Manifest Reference Number.
<br /> llib AWle'rnate Facitity•(or generator) U.S.EPA ID Number
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<br /> Facady's Pftone:
<br /> W 18c.Signalure of Akemate Facility(or-Generator) Month Day.. Year
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<br /> N19.Hazardous VVasle Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 0 1. 2. 3. 4.
<br /> 20.Designated Facility Owner or Operator;Certificallon'of receipt of hazardous materials covered by the manifest except as noted in Item tea
<br /> Pnntedrryped Name Signature Month Day Year
<br /> '�.(-.f. �.1 .l 1 W'(�'. :'�./l. 7 \ �.'.'1. �a -1h.tit;T...-t.. •..:'t 1,21)
<br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. : TRANSPORTER'S COPY
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