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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1'.GeneratorlD Number 2,Page 1 of. 3.Emer ency Res onse Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 0,0 0 4 2 4 8 1 7 1 8W 24-91 6 r� �q �� o0 2�s�py 6 J.J K 5.bLb166M�'V9r6HT LINE INC. ��t �� f tut'tfai.�Itifi�rf 6..;. 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMASVILLE NC 27350 LATHROP CA 95330 Generator's Phone: 3 3 6 8 2 2 5 7 6 0 6, nsg&1 ompiny Name U.S.EPA ID Number a CtO �nvijrcanmental Services C A D 0 5 3 8 6 6 7 9 4 7.Transporter 2 Company Name U.S.EPA ID Number 8. i}'�y p��app �y�ddress S ,e ; U.S.EPA ID Number f d iii bWNf V IV CR+ k Ua_ t; •C�:, s w nit �n r r�.z1-T .;; ''`' &ar rorr, �oa E 1630 WEST 17TH STREET �iso �ON.a;Ft _ r ,fir, P FnR SD85 CP TOX, Q11 LONG BEACH CA 9W13 �� ANI) T �$�t ;a:<<�,�icc��ry�"'ccoft�AN��C�Y�rt f, Facility's Phone: 800 827-•6729 "��cr r ct�r �r t::. ;' cr ost;v �� QP 197a r��1Ii 7}tE 0 2 8 �I 0 9 0 1 9 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, .tiTR hV RL! Si Op 8 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. 8 Y Wt.Nol. 3. NOPJ RCPA PA-ZAPDOUS ao � � WA ft t l�V ID C� � 4. ,�)Vgl,tclilwjpEdAj1effal�,fie,&P20-00249 1.-)+H-7-2$— 2?1.-fl6-7449-- PEI`ROCHEM POS# 2027.01341-21-101392 CA5735, CA57; 7, CA5147, CA5749, CA5750, CA5858, CA 859 tD� zB #1C3� 2 Dr 6 M& M, a2 o� 15. GENERATOR'S10FFEROWS 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 EPA Acknowledgment of Consent. ��'y I certify that the waste minimization statement identified in 40 GFR 282,27(a)(if I am a large quantity tor); (b)(if]am a small quantity generator)is true. W 3 Ga eralorsloff roe rirted[Ty d ame Signatur Month DYear ltax. y Mac, 1 . ternational Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials LLJ Transporter 1 PrintedlTyped Name Signature Month �y Yir gar S -0-V a � Z Transporter 2 PdntedrTypdd Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: it 18b.Alternate Facility(or Generator) U.S.EPA ID Number U L Fatuity's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z C2 19.Hazardous Waste Report Management Method Codest(i.e.,codes for-hazardous waste treatment,disposal,and recycling systems) 0 1. 2. � 3. �� 4. ) V� 20,Designated Facility wner or Operator:Certification of receipt of h zardaus aterials covered by the manifest except as noted Item 18a PrintedlTyped Na s a. L )()�q� Signature Month DD Y r EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR