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Please print or type.(Form designed for use on elite(12-pitch)typewrite 6 130482 7742-"l 5(;PPYY 7.12;2018 Fo m Approved.OMB No.2050 0038 <br /> UNIFORM HAZARDOUS 1.Generator ID kunlber 2.Page 1 of 3.Emergerxy Response Ptgne 4.Manifest Tra Z Number <br /> WASTE MANIFEST C.A�.o ., - 011848920 FLE' <br /> 5 orators Name and Mating Address neral Silo dress(dilTorent dean maiirg address) <br /> M-inmin Hnuse Water Treatment Plant <br /> 130�F Kelsn Road <br /> G!!MG <br /> GIhMMdY/INAd F - <br /> . ransporbr �� <br /> U.S.EPA ID Number <br /> 7. ransporter parry a U. . N <br /> B.Designated Faciity Name and to Address U.S.EPA ID Number <br /> :�Ipan Harhnrc San IOSe LL(, <br /> 10216erryessa Road G A Cr V J J 4'Y J 1 V <br /> 1p�j , ..CA 85133 <br /> Ba, 9b,U.S.DOT DestripE ?mtludmg Oaro �rppping Name,Hazard Class,ID Number. 10.Containers <br /> HM and Packing Gmup(if any)) No. Type Quantity WINd.11 Total 12 Unit 13.Waste Codes <br /> t 7l <br /> 0 NON-RCRA NAZARGOUS WASTE,SOLIDS,T!ESEL.SOIL,PPEi I Z Dftl ., <br /> i 600 � <br /> z 2. <br /> W <br /> rp <br /> 3 <br /> 4. <br /> 14.Special Haring kstructions and PddNonal Information <br /> 1_Cti165680D I Z, x 5S <br /> M' Vpem ufrysgr#rent a Rk. -shipphig n5mb;dnsd.packaged, <br /> marked and labeleclJoamided,and am in all respects h proper condition for transport acoordhg to applicable International and national governmental regulations,0 exportshipment and I am the Pnmary <br /> Exporter,I certify that the contents of this consgnmanl w form to the toms of the attached EPAAdo ow gnent of Consent <br /> I certify that the waste minimization statement idemiried in 40 CFR 262.27(a)(41 am a large quantity generator)or(b)(d lam a small quantity generator)Is true_ <br /> i s s n yped Name Sig fin Month Day ear <br /> q17'1 <br /> J 16.Irlemappra Shirxnerrts ❑Import to U.S. ❑Export from U.S. Port of entryiexlt: <br /> Transporter signature for exports only), Dale I—ing U.S.' <br /> w 17.Transporter Acknowledgment of Recapt of Materals <br /> r, Trans rl Prints typed ante ,�/,, the on y ear <br /> a g N U" 7� 12-11 t Y <br /> Z 7.anspoRer 2 PnntedlTyped Name signature <br /> QMonth Uay Year <br /> 18.Dfsaeparry <br /> 18a.Discrepancy Indiction Space ❑O.ruty Type ❑Residue ❑Partial Rejection ❑Fut Rejed. <br /> Manifest Reference Number' <br /> I Bb'Memale Faality(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fera sPhore: <br /> 18c.Signature of Ahemate Faaity(or Generator) <br /> U Mond Day Year <br /> Q <br /> z <br /> 19.Hazanluus Waste ReportManagement Method Codes(.e.,codas for hazardous waste IrealmerrL disposal,and recydirg systems) <br /> W <br /> D ' <br /> H141 <br /> 1 20.Designated FaaNy r Operator:C tion f r t of hazardous maMrels covered by the manifest except as rested i 18a <br /> Prirtedfryped Name Signature <br /> 3 kw"� 1� E 13 1 fly <br /> EPA Form 8700-22(Rev.POSrPreviousedifift o DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> M-4-merlin gt;d5}ha�g�- .n.jtr,iq. �a Spill ae�enr th?wa<ee♦lin eonec�Mf�c r;ht..nL.d <br />