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` .-`G �y <br /> fv! ,pont or type. a Form Approved.OMB 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 CAL0603I&KW 1 {tfl:33 3i3S t3 { /}3 9 3 GBF <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ACHE:. ,;AW&SUPPLY-L.C?UI <br /> 214 N. SACRAMENTO ST <br /> L001.CA 95240 <br /> Generators Phon •334:3396 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AIYiI'RICAN VALLEY WA:PrE 01L,INC C.AR(AY0272302 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ATE RIC:YGLIE BPECIAL,TY WASTE Sq)bLUTIONS, INC Iv1N!;(4tJLJI I(V24 <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> i�ErM-hLAt�XaJt)L'Ut{ty(x�VA,L,L.(,,. CtA[,)EiLiQ�3fiz41Fi�:3 <br /> 111868 WHITE ROCK RU), <br /> fZV-1C H0 C;tJfirN.VA,GA Otlf X42 <br /> Facility's Phone?f 16'351-(A" � <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1 (JM ",i,WA"r rF-RAMMAF?LIF LK A.11108,NO S.,3, 1301111, s IX)(11 L018 :3:31 <br /> t OWTAINS GASCX IMF — <br /> z 2. ` <br /> L <br /> C7 � <br /> 3. <br /> 4. <br /> F, <br /> 14,Special Handling Instructions and Additional Information <br /> ! Fj#dtJi=IL,E�#b"i�ia()f3•U I ixA: e,C?IL EH(:b#'1:P8 <br /> F—WRGF..PN'Y CONITACT•3d.)HN <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,package <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary" <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a smalLquantity generator)is true. <br /> Geneiators/Offerors PrintedlTyped Name SigpaturJe Month Day Year <br /> Min,4- <br /> i t <br /> _j 1 16.International Shipments <br /> P— ❑Import to U.S. xport from U.S. Port ofentry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transport ntteed Y d Name f Signature.. r""" y <br /> Month Da Year <br /> a 1 �, <br /> Z Tran porter 2 finted/Ty me a,,V V Signat e,' M nth P 016y "YeAr <br /> F .G <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z 1 <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) — -- <br /> 1 2. 3. Notice: State of California requires <br /> generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days: <br /> Printed/Typed Name Signature <br /> f p.0 Box 400 <br /> Sacramen 0, CA 95812-0400 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. t3ENERATOR'S INITIAL COPY <br /> n /� <br />