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MINNI III ONO 111 110010 oil NONNI oil C Ee5 S \v <br /> a + u a R i 1400 a00 -00CBBHD <br /> Please print or type. Form Approved , OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. age t of 3 Emerg y Res ons P�ione 4. Manifest Tracking <br /> Number <br /> WASTE MANIFEST C�50 7q J [3p JTt IIDOG167712 GBG <br /> RM3414and Mallin sC+R ' Generator's Site Address (if different than mailing address) <br /> O BUTT014 AVE <br /> �MNTECAir CA 95336 <br /> Generators Phone: ^ 7247 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> KIERXTAGIZ� CRYSTAL CLEM , LLC 11 L11100013001552 <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> I / <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> HBRITAGS— CRYSTAL CLEAKo LLC <br /> 3450 HOLLYWOOD AVENUE <br /> FREVEPO T ¢ LA 71109 1 <br /> Facility's Phone: i � <br /> ga 91), U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit <br /> 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br /> O a0 /R GidL" ` EOr (AQLMOUS :PTS IONE <br /> t 19M i 1,- <br /> 0 � _ <br /> Z 2, <br /> LU <br /> 3, <br /> 4. <br /> 14, Special Handling Instructions and Additional Information <br /> 1 ) 40DS28 � 10 �68 TSD me 10 � 58 H142 <br /> 15, GEN ERATOR'SIOFFEROR'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, packaged, <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) (i m a sma quantity generator) is true. <br /> Generators/Offerors Printed/Typed Name ature Month Day Year <br /> 00 <br /> ernational Shipments ❑ <br /> El Import to U.S. Export from U.S. ort of entry/exit: <br /> t h„ <br /> i Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name \ Signature Month /D7a�y Year <br /> r O.. <br /> Transporter 2 Printed(fyped Name Signature Month Day Year <br /> r144e, <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space quantity ❑ Type ❑ R idue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> t� <br /> Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> 19. Hazardo s Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> ® 1 2, 3, 4. <br /> 20. Des' n ;Name <br /> ity Owner or Operator: Ce ' a n of recei of hazardous materials covered by the manifest ex s noted in Item 18a <br /> Printe eSignal lh ay Y7q <br /> d14tfilLa V& <br /> EPA For 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNA71 ED FACILITY TO EPA's e4ANIFEST SYSTEM <br />