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7 <br /> 'Please.print or(;;pe. f+++f� :•j j 7 Farm Approved,OMB No.2050.0039 ! <br /> UNIFORM HAZARDOUS f.tlenerator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M612808711 <br /> (fest Tracking Number• <br /> WASTE MANIFEST CAI_(?001�2?Q5 1 Ees-7S -i? ;i.;.. 6 1 2 8 0 8 71�1 FLE <br /> 5.Generators Name and Mailing Address Generalors Site Address(if different than mailing address) <br /> Gc71.1•�ab C:all'turnia, LLC i. <br /> 1910 E. Lathy Road <br /> I.at4mrp, CA 9�l <br /> Generators Phone: 20W249-4719 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> O Awned GhefMoW T'misp ort trlc./DBA ACTE-NVIRC) CAROU( 170W <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number i <br /> Chemical Waste 11l1jaria flenit <br /> 35251 09d Skyline Road GATOOW46117 <br /> KettleZlian City, CSA 9.,7119 <br /> Facility's Phone: <br /> ga 9b.U-S.DOT Description(including Proper Shipping Name,Hazard Class,l0 Number, 10.Containers 11.Total 12.Unit <br /> NM <br /> and Packing Group(if any)) No. Type Quantity Wl.Nol. 13.Waste Codes <br /> f Nogit-RMA Kazardous Waste Sofid(Soil) A yr'� t <br /> Y cZ c� <br /> Z 2. <br /> LU <br /> 0 <br /> RECEIVED - - <br /> 3. <br /> MAR 1 8 2019 <br /> 4. <br /> Con-Fab California LLC <br /> 14.Special Handling Instructions and Additional information \ onrc4ed Nunher '19&311 aa� ient D234.220 <br /> 1) GAC°r'M39 Cry,- <br /> 15. GENERATOR'SIQFFEROR'S CERT)FICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arca are class&4,packaged, i <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport accordng to applicable international and national governmental regulations.If export shipment and I am the Primary t; <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent: <br /> I cerlily That the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Gene ratoes(Offefors Printed/Type <br /> d Name Signature Month Day Year <br /> 16.International Shipme Is <br /> F OImport to U.S. Export from U.S. Port cf entry/exit: .� <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgmenl of Receipt of Materials <br /> LEJ <br /> Transporter 1 Prinledliyped Name Signature/ Month Day Year <br /> 0. <br /> J r <br /> Z t Transporter 2 Printed/Typed Name Signature Month Day Year- <br /> f8.Discrepancy <br /> tliq.Discrepancy Indiation space quantty ❑Type El ❑Partial Rejection full Re;ecfion •'! <br /> Manifest Reference Number: ' <br /> 18b.Alternate FaatiU.S.EPA ID Numberty(orGeneralor) n <br /> U <br /> u- Faclitys Phone: I <br /> 18c.Signature ofARemale Facility(or Generator) Month Day Year I <br /> Q <br /> N19.Hazardous Waste Report Management Method Codes(La.,codes for hazardous waste treatment,disposal,and recycling systems), I <br /> X. <br /> 20.Deskjnaled Facility Owner or Operator.Certification of receipt of hazardous materials covered by the maMfest except as noted In Item 18a •. <br /> Prinledrryped Name Signature f Month Day Year <br /> /dA) ,i <br /> EPA Form 8700.22(Rev.12-17) Previous edifia sareobsolete, _ DESIGNATEDFACILITY T©GENERATOR f <br />