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3425933. <br />Please print or type, Form Approved, OMB No. 2050.0039 <br />UNIFORM HAZARDOUS 1. Generator w Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFESTI an(877)67 Z81111M 0194717. JJ K <br />ti. Generator's Name and Melling Address Generator's Site Address (If different than maleing address) <br />Orchard Supply*1630 do Stericyde CSR Omhard Supply #0530 <br />$151 San Felipe St Ste 1000 189 W Louise Ave <br />laRyMpfalx 77058 antece, CA 95338 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Ppnder <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S, EPA 10 Number <br />21st Century EMI <br />2095 Newlands Drive E <br />Fa t s $ RY4eNV 9940 <br />ga 9b. U.S, DOT Descdplion (Including Proper Shipping Nam, Hazard Class, ID Number, 10. Cohfainers 11. Total 12. Unit 13. Waste Cedes <br />HM and Packing Group (If any)) No. Type Quantity Wtivo1. <br />1. <br />W UN3175, Waste Solids Containing Flammable Liquid, N.O,S., 03 DM 800 P3001 331 <br />4A PG 11 <br />z 2. <br />W . <br />(J <br />3. • <br />4. <br />14. Special Handling Instructions end Additional Information <br />rofiie *0SHFLAMSOL-04 <br />4 #X3425983 <br />ob #18ow16558 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedere that the contents of this consignment are fully and accurately described above the propsr sin g name, and are classified, packaged, <br />marked and Iabeted/placarded, and are in all respects In proper condition fortransport acowding to applicable Intemationsland national gove n I re atio export shipment and 1 am the Primary <br />Exporter, I cedily that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br />I certily that the waste minimization statement identified In 40 CFR 262.27(x) Of I am a large quantity generator) or (b) (if I am a smalls a r)' e. <br />Generatar's/Offeror's Pdnted/Typed Name Signahae Month Day Year <br />ick Vaccad on behalf of Orchard SuRILIM#0530 <br />16.InternationalShipments <br />F. ❑ import to U.S. ❑ Export from U.S, Pott of entry/exit: <br />? Transporter signature (for exports only): Date leaving U.S.: <br />14 <br />IX 17. TransporterAcknow.edgment of Receipt of Materials / <br />Transporter 1 Pdntedlfyped Name Signature�All�_ Month Day Year <br />It�S Vaccariv; ka Ila <br />ransporter 2 Pfintedrryped Name Signature Month Day Year <br />ti <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type Q Residue ❑ Partial Re eciion ❑ FuA Rejection <br />Manliest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Fadllty's Phone: <br />Woffohnflo <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recydIng systems) <br />4. <br />2D. Designated Fad Ity Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />Frintedfryped Name Signature Month Day ear <br />EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's 13•MANIFEST SYSTEM <br />