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11 � 1 1� 1l � <br /> III loll 1111111111 V : i �Cw �jRz. <br /> (,c R3ut.a- : - ROUTE i 1-490#: no-- $ ,° <br /> Please print or type. Forst Approve . o. D 4-0Q33 <br /> UNIFORM HAZARDOUS II.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Trackin Number <br /> WASTE MANIFEST CAL )00 o 0G-424t- 9300 r r1 0063�3151 GBF <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 'AL FORNIA AUTOSPORT <br /> '; 80 BUTTON AVE <br /> .]'#TELA. CA 95336 <br /> r n,- ,z <br /> Generators Phone: n -^ <br /> B.Transporter 1 Company Name ` - U. . A7D"Num^.- " <br /> EP.ITAGE-r'RYSTAL CLEAN, L R Cf' 0 O 1 3 0 O 6 ?_ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> N09N* V <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> 'ERITAGE-LRYSTA-L GLEAN, LLC I L R 0 0 0 1 3 0 0 6 2 <br /> A50 HOLLYWOOD AVENUE <br /> HREVEPORT, LA 71109 Sift; 5215-0125) <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 0W-I30T/RGFtTL R-"G1,L?kTECr NW:'lZr:7l� <br /> a <br /> ��) (221) <br /> w <br /> z 2. <br /> 0 <br /> 3. <br /> 14.Special Handling Instructions and Additional Information <br /> 11 CC: 40`_5219-10-58 `x`30. 10-59 <br /> -.-alt-6c1 riftAined by penarator carJars agdm-f at."+Itt.mE off ImIal tnrt2p:jnbr to add of SL1b31€[tttb addmartsl tr'bf'1spnef3 or,jartibraims E8nw. <br /> 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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intomati i 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 EPAAcknowledgmenl oft. <br /> I ce0y that a wa to minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity on rat (b) f 11 a small quantity generator)is true. <br /> rator'sl0fferor's Na t re Month Day Year <br /> V� <br /> �+ Is-1 ?Z 1 !7 <br /> 16.Intemationai Shipments <br /> F- 1:1Import to U.S. Export from U.S. P of antrylexit: <br /> 9 Transporter signature(for exports only): Dae leaving U.S.: <br /> CC LU <br /> f7.Transporter Acknowledgment of Receipt of Matelots <br /> Transporter 1 PrintedlTyped Namel Signature Month Day Year <br /> a S 6) S 23 <br /> Z Transporter2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity ype 1:1 # # <br /> T Residue Portia!Rejection Full Reaction <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> LQ 18c.Signature of Alternate Facility(or Generator} Month Day Year <br /> a <br /> Z <br /> An19,Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> © 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print (Typed Name 2zi�4-'SIGNATED <br /> Month Day Year <br /> IS IT <br /> EPA Form 8 0-22(Re .12-17) Previous editions are obsolete. FACILITY TO EPA's e-MA41FEST SYSTEM <br />