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f 111E 111ff 11f1111111 If11f fflff(111111111 If1f11f f 1111111E Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000409953 1 (800)326-1221 S.Q r tQas�Namr ftd oli Vj!,Less# 1164 / MATTHEW SALAIZ G�atp�,JiteAc r hff, Lrl�maVnjnf&J-9 MATTHEW SALATZ 24717�fWLEE RD 2477 2477 NAGLEE RD TRACY, CA 95304-7324 TRACY CA 95304-7324 (209) 83^c-9373 GEN: Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number HERITAGE TRANSPORT LLC - TS HAYWARD I IND058484114 7.Transportr 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number HERITAGE ENVIRONMENTAL SERVICES 284 E STOREY RD AZD081705402 COOLIDGE, AZ 85128-9205 Facility's Phone: (520)723-4167 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Noi. o X 1. RQLUN 1993 WASTE FLAMMABLE LIQUIDS N.0.S. , '� F003 D€01 212 r- 3 PGI 1 (ACETbNE, ISOPROPANOL), (D001 b03), f j EAG#12A z 2. Uj X RQ UN3248 WASTE MEDICINE LIQUID y� �/ Ji 11 Ct:€ 2 U031 FLAMMh LE, TbX IC, N.0.S. 3(9. 1),PGI'I /� j' V (ETHANOL SELENIUM) (D01�. D010) ERG#131 U039 U112 U122 3. Xt RQ,UN3249 WASTE MEDICINE SOLID, TOXIC, U002 311 U112 N.0.S. 6. 1,PSI I, (SELENIUM, SILVER), (D011 D)10) kRG#151 I U122 U154 U188 4. X NA3082 HAZARDOUS WASTE, LIQUID, N.O.S. ,9, U122 343 PGIII, (FOI` ALIN),ERG#171 14.Special Handling Instructions and Additional Information 1.W1 1411810 LDR 2.145 01411440 LDR 3.W6 01412922 LDR 4.W3 Q1412230 LDR C 126089131 GT 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 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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 small quantity generator)is true. Ge rators/OfferOrs Printed/Typed Name signatuiie Mon Da ear �CC &Cv ar; f J 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port of antrylexit: Trans iter signature for exports only): Date leaving U.S.: LU 17.TransporterAcknowledgment of Receipt of Materials 12 Transporter Pdntedrr a Signature on a ear Q Transporter 2 PdntedfTypgd N �� ® /� Signature onth Day '�. S� 18.Discrepancy 18a.Discrepancy Indication Spare R Quantity ❑TypeEl j j Residue Partial Rejection Full Re ection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facilitys Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. H141 H141 H141 H141 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as ed in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED F IUTY TO DESTINATION STATE(IF REQUIRED)