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3425933 • <br /> Please print or type, Form Approved. OMS 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 0. 19 4 717 6 9 JJ K <br /> 6. Generator's Name and Meiling Address Generator's Site Address (If different than mall<ng address) <br /> Orchard SupplyM530 do Stedoyde CSR Omhard Supply *0530 <br /> 5151 San Felipe St Ste 1000 189 W Louise Ave <br /> §RrIRllfiFltadex 77086 antecals CA 85338 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> Pander Environmental <br /> 7. Transporter 2 Company Name U.S. EPA ID Number - ' <br /> Be Designated Facility Name and Site Address U.S. EPA ID Number <br /> 21st Century EM <br /> 2095 Newlands Derive E <br /> F t s t ,�ria: 5715471110 <br /> NV 89408 <br /> 9a, 9b• U.S. DOTDescrip8on (Including Proper Shipping Nano, Hazard Class, ID Number, 10. Cohlafners 11. Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WfdVof. <br /> o UN3175 , Waste Solids Containing Flammable Liquid, N .O .S. , t}3 QM 800 P331 <br /> 4 . 1 , PG II <br /> M 2. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions andAdditforrat Information <br /> roflle *0SHFLAMSOL-04 <br /> d #3425933 - <br /> ob#18-16858 <br /> 154 GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratefydescdbed above the proper chi i1g name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects In proper condition fortransport according to applicable International and national gove I re ado export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I cerfify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a smallq�i a r) ' e. <br /> GenerataesfOfferofs PdntedfTyped Name Signature ,� Month Day Year <br /> ick Vaiocari on behalf of Orchard Supply #0530 <br /> ,r 16, International Shipments 1_((��tt <br /> E., ..J import to U.S. ❑ Export from U.S, Port of entrytexlt <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransNrWAd=WedgmentofReceiptofMatedaisLU <br /> f <br /> Transporter 1 Pdnted/Typed Name Signature l Month Day Year <br /> 10. 1ok Vaccarl <br /> 11 !7 14tq Ila <br /> ITranspoder2 Printed/Typed Name Signature Month Day Year <br /> 18. Discrepancy <br /> 189. Discrepancy Indication Space n quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fug Rejection <br /> Manifest Reference Number <br /> 18b. Alternate Fid (or Generator) U.S. EPA ID Number <br /> J_ <br /> u. Faciilty's Phone: <br /> iku <br /> m 18c. Signature ofAllernateFacility or Generator) Momkh Day Year <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 3. 4. <br /> 20. Designated Fadity Owner or operator: Certification of receipt of hazardous materials covered by the manifest except as nded In Item 18a <br /> PrintedNypod Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12A7) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />