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Pleas fII�II�INIIININUIN�INN <br /> e pant or type. IN�INIINIIIIIIiINNNI�IIINB�I <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> FGenerators <br /> ZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackln Number <br /> NIFEST CAL000429774 1 (877) 577-2669 01301701 FLE <br /> me and Mailing Address n 1 ed e y an ag a r- Generator's Site Address(if different than mailing address) <br /> Amazon.com Services, Inc. (DCK1)05-0080 2403 West Louise Avenue Amazon. com Services, Inc. (DCK1> <br /> 2403 West Louise Avenue <br /> Generator's Phone: Manteca CA 95337Manteca CA 95337 <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> =Company <br /> cle S ecialt Waste Solutions Inc MNS000110924 <br /> r8-Designated <br /> U.S.EPA ID Number <br /> � tL� <br /> Facility Name and Site Address Rho Chem, LLC <br /> U.S.EPA ID Number <br /> 425 Isis Avenue <br /> Inglewood, CA 90301 <br /> Facilitys Phone: 323776633 CAD008364432 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> X 1RQ, UN3267, Waste Corrosive liquid, basic, 1 DF 00123 P 12 D002 <br /> organic, n. o. s. (Sodium Hydroxide, Potassium <br /> w <br /> Hydroxide), 8 PG II (D002) E G#15 <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> 1. 109732(Sasic / Corrosive / Organic Loosepack) <br /> 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment 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)(ifI am a mall quanti generator)is We. <br /> Generatoes/Offeror's Printed/Typed Name Signature <br /> Month Day Year <br /> L <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. P of try/exit: <br /> z Transporter signature(for exports only): <br /> Dat aving U.S.: <br /> u 17.TransporterAcknowledgment of Receipt of Materials <br /> e Transporter 1 Printad/Typed Name Signature <br /> � Month Day Year <br /> Isidro Martinez <br /> Transporter 2 P inted]typed Name Sig <br /> ure <br /> 5 Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> 1 ❑Full Rejection <br /> Ido.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> 18c.Signature of Altemate Facility(or Generator) <br /> Month Day Year <br /> 19.Hazardo W ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,Tan systems) <br /> 1. 14 2, 3. <br /> 4. <br /> 20.Design ility Owner or per rtifcation ofrecekit of hazardous materials covered by manifest ezce ed in It 18 <br /> Printed/T ped Nam Signature <br /> MI may �Ype� <br /> Form 8700-22(Rev. 12-17) Previou"dA <br /> e lilinns aro oro —{L �rj <br />