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Please print or type.(Form designed for use on elite(12-pitch}typewriter.) Form Al OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 Of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L D 0 0 4?i 5 7 4 ¢31{i-124-9 x,010 J J K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> UTFITTER9 68 <br /> f5 s i'PYUTP'i*iD&fE 100 <br /> LAKE IN Ti'ii• 44113 IL 901 49W PACIFIC AVE <br /> Generator's Phone: 209 951-4753 STOCKTON CA 96207 <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 41RONMENTAL SERVICES C A 110 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 'tw E. Fit k i-Via. <br /> LWBANWE'LES CA �l�O(34�5"��i!�O�'� <br /> Facility's Phone: (800499-7145 <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)} No. Type Quantity Wt.Nol. <br /> 1 AbN1993,W&TE FLAMMABLE LiQUI ,W' ' <br /> DI 'ILAATE:,$.3. PG li 8001 1331 <br /> G <br /> z 2, <br /> L <br /> i7 <br /> 3. <br /> i <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS PROFILE#981:19040204-01 <br /> PETROLEUM DISTILLATES#'P5WO0l -APPROPRIATE PPE EQUIPMENT o-�d 1 )(..5 <br /> 15. GENERATOR'SIOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intematianal and national governmental regulations.If export shipment and 1 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(p)(if I am a small quantity generator)is true. <br /> Genet r'sl0fferor's Printecirryped Name Signature Month Day Year <br /> J 16.In emational Shipments <br /> Z Ll import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(far exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> r � I JS Il <br /> a Transporter 2 Printedrryped Name Signature Month Day Year <br /> !Y <br /> I-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quant;ty Type ❑Residue ❑Partial Rejection <br /> El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> � 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> 2E <br /> ro <br /> LU 39.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 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 /> Printecirryped Name Signature Month Day Year <br /> )c cc C' <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />