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Please print or type. Form Approved.OMB No.2050-0039 <br /> WNIFORM HAZARDOUS 1•Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4.Ma((n�ifest Tracking Number <br /> WASTE MANIFEST I:A1D002g6071 2019-604-81900 2 0, 0?273 JJ K <br /> 5.9znerator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> AL WAGNER <br /> 1012 S ACACIA RD <br /> RIPON,CA 95366 <br /> Generator's Phone: 209-604.8190 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> George W. Lovrry,Inc. CAR000047019 <br /> 7.j a sporter2CompanyNam j _.. U.S,.EPA 10.Number <br /> 6--T <br /> 8.Dgi Eg-E � C U.S.EPA ID Number <br /> 3i� CALOOLT2 F596 <br /> 11620 . BRUNDAGE Ln <br /> BAK SFIELD,CA 93307 <br /> FaWlity's Phone: 661'323-82W <br /> gal 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 /> X 1' MON RCRA HAZARDOUS WASTE S0LI0 (oily absorberd) DM = — <br /> o t7p <br /> z 2. <br /> W <br /> C <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information U��> <br /> ERG#i 171 INVOICE#f I WQ �Z � PROFILE#1 <br /> WEAR GLOVES <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 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 EPA Acknowledgment of Consent. <br /> I ce that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gene%tor)or(b)(if I am a small quantity generator)is true. <br /> Gep ator fferoPsPn ted/Type gn re ') Month Day Year <br /> �� _e U' - <br /> 16.International Shipmen <br /> Import to U.S. " ❑Export from U.S. Port of exit: <br /> Z Transporter signature(for a <br /> F— Elports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials 14 <br /> w <br /> O Transp� t`Pr�n Name Signature Month Dy ear <br /> is 8 <br /> aTransMr 2 Prirj9qrryped Name Signature Month Da Year <br /> 18.Jscreancy I 4ndm <br /> 18a.Discrepancy Indication Space ❑ Quantityyp 1 ❑ 1 <br /> ❑T e ❑Residue El Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> � <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and rer,ycling systems) <br /> / 2. T. <br /> T <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name Signature Month Day Year <br /> v <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br /> ti <br />