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417 <br /> 13 <br /> Form Approved . OMB No. 2050-003; <br /> 'age 1 of 3 Emergency Response Phone r t 4. Manifest Tracking Number <br /> - � 0 14L a r ,a G B F <br /> Generator's Site Address (if different than mailing address) <br /> U .S. EPA ID Number <br /> Heritage - <br /> Crystal C] e an U.S . EPA ID Number <br /> U .S . EPA ID Number <br /> 14,kl � <br /> � � . <br /> Sri10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> No. QuantitYWt.Nol. <br /> eiv <br /> TYP <br /> 9 � I L„ — <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 'VIII 1 <br /> h <br /> WORK ORDER NBR ; 00 -00CE5314 .. _4 . _.. <br /> SERVICE REQUEST NBR : 462489 <br /> i <br /> CUSTOfdER ID NBR : 353697 i <br /> COldl^tENTS : <br /> EIdERGENCY NBR : 800 - 424 - 9300 <br /> DATE : 2 / 26/ 20419 2 : 51 : 30 Ptd <br /> CRYSTAL CLEAN REPRESENTATIVE : SEAN MASON <br /> CUSTOMER/ SHIPPER : <br /> CALIFORNIA AUTOSPORT <br /> 180 BUTTON AVE t are fully and accurately described above by the proper shipping name , and are classified, packaged, <br /> IdANTECA , CA 95336 icable international and national governmental regulations. If export shipment and I am the Primary <br /> CONTACT NAME SERVICE Yusef 209 - 605 - 7247 vledgment of Consent. <br /> lerator) or (b) (if I am a small quantity generator) is true. <br /> nature Month Day Year <br /> GEN , STATUS : APPLIED <br /> FEDERAL EPA ID NBR : <br /> ID NBR : CAL000430494 L5 . - f o of entrylexit: <br /> E STATE EPA Date leaving U .S. : <br /> e COMMENTS : <br /> - - - - - - - - - - - - - - - - - - ature , <br /> Day Year <br /> Month Da i LLl <br /> V <br /> Month Day Year <br /> DESTINATION : - - _ _ _ _ _ _ - - - - ature <br /> ~ HERITAGE - CRYSTAL <br /> CLEAN , LLC <br />( 30989 SAID CLEfdENTE STREET <br /> ❑ Residue ❑ Partial Rejection LJ Full Rejection <br /> HAYL4ARD CA 94544 <br /> Ii : 847 - 836 - 5670 <br /> phone Numbe _ <br /> Manifest Reference Number. <br /> I - - - - - - - - - - - - - — U .S . EPA ID Number <br /> _ CARRIER : HERITAGE - CRYSTAL CLEAN ) LLC <br /> wMonth Day Year <br /> p EPA ID NBR : I1. R000130062 <br /> I Q Phone IJumber : ( 847 ) 836 - 5670 <br /> Z - - - - - - - - h � " no recycling cCingsystems) <br /> av � <br /> RTI 1 o AnT146 3 Q . <br /> W 1 <br /> O <br /> 20 . Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> Printed/Typed Name <br /> EPA Form 8700-22 ( Rev . 12- 17) Previous editions are obsolete . <br /> I � q ^' 1 11j + 1 In <br /> f <br /> f <br />