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eU 611. RVtiS Tao cog Tif-r <br />Form Approved. OMB No. 2050-0039 <br />Please <br />A <br />print or type. <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />- <br />1. Generator ID Number <br />CAC003124315 <br />2. Pagel of <br />1 <br />I 3. Emergency Response Phone <br />I 888-785-7225 <br />14. Manifest Tracking Number <br />015884900 FLE <br />5. Generators Name and Mating Address Generator's Site Address (if different than mailing address) <br />Central Valley Waste Central Valley Waste Sendices <br />1333 E. Turner Road 4592 Woodbridge Rd <br />Lodi, CA 95240 'Lodi, CA 95242- <br />Phone: 2(19.'111.4117 Generator's <br />6 Transporter I Company Name <br />U.S. EPA ID Number <br />Adlanced Chemical Transport Inc./DBA ACTemiro CAR000070540 <br />Transporter 2 Company Name <br />US. EPAID Number <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />Chemical Waste Management CA T000646117 <br />35251 Old Skyline Road <br />Kettlernan City, CA 93239 <br />Facility's Phone: 5S-386-9711 <br />9b. U.S. DOT Description (induding Proper Shetimg Name, Hazard Class, ID Number, 10 Containers 11 Total 12. Unit 13. Waste Codes ga, <br />HM and Packing Group (if any)) No Type Quantity Wt..voi. <br />ce 1 .Non-RC RA Hazardous Waste Solid (Dirt, Hydraulic Oil) CM 7_0 3521 <br />1— 1 4 GENEI Special Handling Instructions and Additional Information Project Nuriber 299574 Documert 0372725 <br />1) CA620101 CEC- e9'.../ / -V -z.' <br />--- <br />iv7 2---. <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately deserted above by the proper shipping name ard are classified. packaged. <br />go mental regulations if e • • iiiit'' errent and lam the Primary marked and labeled/placarded, and are in at respects ir proper condition for transport according to applicable intemational and national <br />I <br />Exporter, I certify that the contents of this consignment conform m the terms of the attached EPA Admoveledgment of Consent <br />I certify that the vraste minimization statement identled in 40 CFR 262.27(a) (if 1 an a large quantity generator) or (b) ltil am a small qu ty, geneXii <br />s/Offeror's Printrid Name Signature Month Day Year <br />617 f•- blial/Yfrn—S A,PZ_WiLd74/ W. ?lf/ I #,/, Vs717-i‘ 24 <br />.„). rnational Shipments International / <br />mport II to U.S. Export from U.S. Port of entryesit <br />t— <br />Z Transporter signature (for exports only): Date eaWng U.S.: TRANSPORTER I 17. TranspormrAchumcernerfl of Receipt of Materials <br />Transporter 1 PnntodJTyp Name Signature Month Day Year <br />I --zcs9' 1.,7 izA 1 zi <br />Transporter 2 Pnnt Name Signature Month Day Ye ar <br />I I I <br />Disaepancy 118 <br />18a. Discrepancy Indication Space . Quantity Type 111 Residue E Partial ReOcnon 111 Full Rejection <br />Manifest Reference Number. <br />:i <br />C..) <br />IL. <br />16t) Alternate Facility (or Generator) U.S.EPA ID Number <br />Facility's Phone: <br />° t II— 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Hazardous Waste Report Management Method Codes (i.e.codes fcr hazardous waste treatment. disposal, and recycling systems) <br />0 <br />WI , 2 3. <br />Designated Faal . or Operator Cent patio receipt o hazardous matenats covered by the manifest except as need in Item 18a <br />Pnreedffypied N <br />trU4/. ( <br />1 Signature Month Day Year , <br />I <br />I --712A4;114 <br />EPA Form 8700-22 (Rev 12t7) Pre us edibon re obso)ete. •