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Compliance Report August 4, 2020 <br /> Store No. 1554—Stockton, CA Page 6 <br /> ATTACHMENT C <br /> Waste Manifest <br /> Please print or type Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifestrii Number <br /> WASTE MANIFEST CAHII.-JO G?�d4 1 t3FS 1-;6 ii'<'`1� 0114�r:5651 FL E <br /> 5 Gerea:ors Name and Mailing Address Generator's Site Address(if cliflerent than mating address) <br /> :122117 lAwn rler Ln <br /> Stm*tnfl,CA 4521' <br /> GeneretWs Phono: 4 '"� <br /> 6.TrarepaM <br /> -U.S.EPA ID Number,, e <br /> .--.1 miT .,tit :,r m•I,r <br /> -::a•I?nlnuzn!r•tt, <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U S.EPA ID Number <br /> C.111foI da Of Tftt lig fe- LI1� <br /> 53W CIIa114 Rriad" 861610 11 <br /> MtX1H8to t t,gy?ty7 <br /> Facili 's Phone'. � � <br /> ga_ 9b.U.S.DOT Description Including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If any)) No. Type Quantity WLNd. 13.Waste Codes <br /> t. V;,❑ .(t 1I�1.arc9r,4r.,4Va.I Cttjm.l it . .'i1 -r <br /> P - - — <br /> i z. <br /> W <br /> 3 <br /> 4 <br /> 14 Speail Handling Instructions and Addifional Inbrmation .°• I : '�- I ,, - <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 narie,and are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to applrable mlemanonaland national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of chis consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify[hat the waste midmlzation statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is We. <br /> GaneraWs/Offefoes Printedfryped Name ' Signalum hIcnlh Day Year <br /> L. <br /> j I6.Intemaft shigments . <br /> F LJ Import to U.S. ❑Export from U S. Pal of entryleLt. <br /> M Transpala sigratae(for exports orayl: .Date ktavirg U.S.: <br /> Of 17 Transporter Acknowledgment of Receipt of Materials - _, <br /> Transpofter I PnntedrTyped Name SgmMMr ' n Month Day Year <br /> Z Transporter 2 PwitediTyped NamF Soren Month Day Year <br /> F <br /> 18 Discrepancy <br /> 16a.Discrepancy Indoaoon Space ElQ �-1uantity ❑Typn L_I Re;a,e ❑Partial Rejection ❑FW Rejection <br /> hlandest Reference Number. <br /> 18u.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facrlity's Phone. <br /> a 1Sc Signature of Altamate Facitily(or Generator) Month Day Year <br /> 2 <br /> rA <br /> 19 Hazardous Waste Report thanagement Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2 3 4 <br /> ♦IN, <br /> 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prudedfiyped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.12-17)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> /` <br /> APEX <br />