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FormAvamved. OMB No. 2950-0039 <br />EPA Form, 0700-22(Rev 12-17;. Previous edl6orsare obsalete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />fJNIFOF1Sl NAZARD01l5 <br />Number <br />t' 10 Num <br />Page t of <br />3. Ermergemy Response °hare <br />1 NaNlytTwtlfler <br />Mw~ <br />0220 N71447 JJK <br />V"TEM"f ST <br />CAL 000428650 <br />2 <br />WSui-39,10 <br />5. Generator Name and Maung Address Generators Me Address id diffarent than malkng address) <br />UY of Tracy C-ky Df • on" Wiei 7reabrom# Plant <br />ISM $ Tatty W49 $�Cy <br />Tf&cy MW <br />Tracy GA 96377 Tracy CA. 9 377 <br />Ganeramt's Phare: <br />6. Transpwroer 1 Company Pcne <br />U.S. EPA :0 Number <br />Environnum to l Lquisfics,Erie. <br />G A R 0 0 0 2 17 5 1 <br />7 Transporter 2 CoWany Nana <br />US EPA 10 Number <br />6 Designated °ac" Name and Site Address <br />U.S. EPA ID Number <br />H4Vm i TSOF IAC. <br />1 90 W. Monte Avenm <br />9loomir gbn CA 92316 <br />ga <br />9b. US. DOT De6(rt W (n *Airg Proper Shippirg Name, i4azard Class. IO Numbs, <br />- 23cfdv &OW Ir <br />10. Containers <br />11. Toldt <br />12- Umt <br />`3 Was le Code <br />No. <br />Type <br />tbd <br />Oue* <br />Wt1Yal. <br />ee <br />0 <br />1 % <br />ICON ,rZC11�f tom' QvS �(� <br />Z <br />. - ..1. <br />� <br />c.c <br />LU <br />zW, Hazardous ftsft (PV-"&-) <br />Igo <br />3N60-RCRA �fmzambm Mboe SoUd (Emtltyartnm) <br />°Non-RCRA Hazardous Waste Sig © <br />Z <br />1 <br />Ctrl aavm s) <br />HMXMV kahm5m m41 em RIP <br />,mss,,: �e�a•x <br />r <br />14 <br />z� /�d�YK^� CYxsrx) 1riz` �s,� t�wwlsrz�s's <br />Z <br />Lia <br />s �6 <br />/a .cI <br />15. WVRAMWSIOFFEROR'S CERTIFICATM; I hereby declare that the mnkants of this Mae fi&y and accuralety described above try 7me proper sh spirg name, and are ciasslFed3. padogad, <br />marked and Iabeledlplacardled, and are in all respects t+ proper mndrbw. for transport smordNg to applicable intemabonai and rational ypvemme,tW regulations +f export stuprrmt <br />and I an the Primary <br />Exporter. I certify that the mate-& o`this mns:gr TWR mrform to fttC tetms of to abachad 5PAAmlowledrgmeM of corserd. <br />I cer* that the waste irmmi nation steteament ideitfied in 40 CFR 262.27(&) ,fit ; am a targe quan;ty Werawal or (b) (It am a sinal <br />yped n <br />Along, Day Year <br />� <br />18. kmtemabbrrel SirpmeNs <br />impart to U S. Export from U.S. Dort of et"Ie)dl <br />_ <br />? <br />Transpor�r ggrtahaa Itorraports oras 1: Date lion" t r. S.: <br />Cd <br />LLI <br />17. Transporter .Adumvaledgrre t of Receipt of Materials <br />0 <br />O <br />Tretgparler fiemaMot*DayYea <br />5dgi <br />Transporter2OrmtedRypedHam <br />4j.(J/ 10, <br />`Acro.!' <br />nature <br />Day Year <br />18, Dtscrepeny <br />18a. Cisaeparvy Indication Space Canary ❑type ❑Residue <br />ElPartlal Reiecwlan <br />Or j Rejecion <br />Me-*% R8f8rence Number: <br />18b. Alternate Faebly for Gemrstor) <br />U.S. EPA to Number <br />J_ <br />Gi <br />Fulty's ?hone: <br />18a. Sigranire of .4bemata Facity for Generaweli <br />mcnth DRY ar <br />Q <br />19. Hazardous .'haste Repor: Ltanagement hteniad Codea (.e,. caries forhazardous waste treatment disposal. and Rcy<Jing systems) <br />1. <br />2, <br />3. <br />4 <br />I-- <br />- . — 44 em 0 m ells NO% ON mcaft W in" oil <br />Name <br />Day Yea <br />EPA Form, 0700-22(Rev 12-17;. Previous edl6orsare obsalete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />