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11111111111 ■11 #1111 �'� 10E�SS,o\J Loc.- CARIM Route: OAYJjAlgD — ROMZ 1 R'49: 00-OOCESRD Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS t•Generator 1D Number 2. a e 1 offoger Res an Pjone 4,Manifest Trackin Number WASTE MANIFEST Q(� is 9 - y4- J +n J 1006167712 B F 5.GCgrfGli§eWA�r+Ad{dlrreeesss s Generator's Site Address(if different than mailing address) ED BUTTON AVE �ANTZCAI CA 95336 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number ERITAGE—CRYSTAL CLEAN, LLC 1ILRO00130062 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address LLS.EPA ID Number ERITAGE—CRYSTAL CLERK, LLC I L R 0 0 0 13 0 0 5 2 950 HOLLY1 MD AVENUE HREVEPDRT, LA 71109 �3?S) 525-0125 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.NOI. 13.Waste Caries 7i—D0TjP.CF& REGVLA=D r (AQUEOUS PARTS WONE Q LFAIRM) (221) 19M 1IZ cm, 2. LLF 3. 4, 14,Special Handling Instructions and Additionai Information 1) CC:40§528--10-58 TSI,7: 10-58 M42 15. GENERATOR'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, marked and labeted(placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment=form to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization slatement identified in 40 CFR 282.27(a)of I am a large quantity generator)or(b) i a sma quantity generator)is true. neratoeslOfferor's PrinledlTyped Name _ ore Month Day Year 1 emotional Shipments F, 11Import to U.S. ❑Export from U.S. ort of antrylexit: ? Transporter signature(for exports only): Dale leaving U.S.: W 17.TransporterAcknawledgmenl of Receipt of Materials Transporter t Printedrryped Name Signature Month Day Year ? MAC Z Transporter2 Printedrryped Name Signature Month Day Year Gll-,� C? .3 1 j I 18.Discrepancy 18a.Discrepancy Indication Space p Quantity Type R -due ,artist Rejection full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U tQi Facility's Phone: 18c.Signature of Altemale Facility for Generator) Month Day Year a N19.Hazardo WasteR port Management Melhod Codes(i.e.,eodes for ha2ardous waste treatment,disposal,and recycling systems) 11 . 2. 3. 4. 20.Des' n d Facility Owner or Operator:Cev4n of rete- of hazardous materials covered by the manifest ex s noted in Item lea Printe ed Name Signat th y Y IL I Ir EPAFo 8700-22,Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM