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3425933 . <br /> Please print or typeo 00111 Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 1 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL13013389913Z0. 19 4 717 6 9 JJ K <br /> 5. Generator's Name and Mailing Address Generators Site Address (ff different then mailing address) <br /> Orchard Supply #0530 oro SUricyde CSR Omhard Supply *0530 <br /> 5151 San Felipe St Ste 1000 189 W Louise Ave <br /> tG§RfrffCdFSfede 77058 jjoyoy�jaaganteca, CA 95336 <br /> 6. Transporter 1 Company Name U.S, EPA ID Number <br /> Bander <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U,S. EPA ID Number <br /> 21st Ceriury Egli <br /> 2095 Nevdands Drive E <br /> ag s ft NV 89408 <br /> : (776) 57154780 80091533 <br /> ga. 9b. U.S, DOT Description (including ProperShfpping Name, Hazard Glass, ID Number, 10. Cohtalnera 11. Total V. Unit 13. Waste Codes <br /> HM and Packing Group (If any)) No. Type Quantity Wt.Noi. <br /> 1 . <br /> o UN3175 , Waste Solids Corttaining Flammable Liquid, N .O .S. , ' <br /> s 4 .1 , PG ii 03 DM 600 P <br /> z 2, <br /> W <br /> 3 <br /> 45 JAN 1 1770 <br /> 14. Special Handling Instructions and Additional Information ENVIRONMENIACTI <br /> rofiile #OSHFLdAMSOL-04 DEPARTMENT <br /> a #3425933 , <br /> ob-#18*18558 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above the proper ship g name, and are classified, packaged, <br /> marked and labeledlplacarded, and are in all respects In proper condition for transport according to applicable Intsmallonaland national gove n I reafio export shipment and I am the Primary <br /> Exporter, I ce* that the contents of this conslilnment conform to the terms of the attached EPAAcknowiedgment of Consent <br /> I cer6(y that the waste minimization statement Identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a small LgC a r) e, <br /> GenerataesfOfferors PrintedfTyped Name Signature Month Day Year <br /> ick Vaocar' on behalf of Ora and SupplyOM530 <br /> ,.1 16. Internalicnaf Shipments tu—t <br /> Import to U.S. ❑ Export from U,S. Port of entrylexib <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. Transp AKAeknowedpontofReoeiptofMateAals / <br /> Transporter 1 Printedffyped Name Signature Month Day Year <br /> idc Vacr„ari19 1414 <br /> Transporter Printed/Typed Name Signature Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space F1 Quantity ❑ Type ❑ Residue ❑ Pastia( Rejection ❑ Full Rejection <br /> Manifest Reference Number <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> v <br /> w Facility's Phone: <br /> 18c. Signature of Alternate Pacillty or Generator) Month Day Year <br /> z4 <br /> 0 19. Hazardous Waste Report Management Method Codes Q.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> G 1 . 2. 3. 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 1 Be <br /> Printed/ typed Name I I Signatme- Month Day ear <br /> EPA Form 8700.22 (Rave 12A7) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />