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46 / 11 / 2021 1 . 52 PH FAX 2099488625 AMCE SAW 0003 / 0003
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<br /> please rint or type.
<br /> 1 . Goneratur ID Number Form Approved, OmB No. 20owOM9
<br /> UNIFORM WAZARaotlg 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number pD
<br /> WASTE MANIFEST CAL0001 1 �. , D c
<br /> t3trt�74( -1449 �� D ,j ;" f
<br /> l 8. Generator's Nand and MaNing gddress SAW Generator's Site Address (If different than mailing addreas)
<br /> U04 I:• (VIAItit f
<br /> `U tt" CK t ON , CA E1��1Ja
<br /> Generates PhonaU9'g48 6735* 105
<br /> 8. Transporter 1 Company Name U.S. EPA ID Number
<br /> Afu1EF#;QN14 VAi r.y WA51F_' is L. , INC , CAR0002723tY
<br /> 7. Transporter 2 Company Name U,S, EPA ID Number
<br /> ;; i'£ I21t;`ri. 1.E'_ ti;T°Fdt, IP� . I ti' rte i P f 1t.t3 {"1C}fd 1, Itds :• NIN'if1 I061 '10112LI
<br /> 8, Dasignaled Facpiy Name and Site Address-
<br /> fit, Li::. U.S, EPA ID Number
<br /> + �tf ••IWP4t;lIGt,;rjRtJ4
<br /> 1 11J10f:71 WHITE lrt(wic Y 1. € tltt#yetf)ftfi •A1}9 i
<br /> t'4Ai`d� ,f'iE� f; C�tit?C)VA,
<br /> Facl8ly's phorto
<br /> JHM
<br /> gb, US. DDTDescaip(lon (Inckttling Proper $hipping Namo, Hazard CI s, ID Number, 10, Containers 11. Total 12, unit
<br /> end packing Group (f any)) Na, Type Quantity WtNoL 13. Waste Codas
<br /> k 1 . ROt L4414t••ej , WAL^,T'F= Ir=f- AW4Atit �462, 1l31F1<Y, r Y.> . ;;. . '; , 6 C,;i ' , t !3M �ti C* C111fJ1 4Jd1 ✓; ;;;s 't
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<br /> 14. Special 'HandliAgfnstrudonsandAddlumallnionnefton
<br /> € f1 )F;Ip. e, ft` 4*80;1•1011 Cyltic; ti, OIL, ER<V 1 .2:3
<br /> I NIIEE tCC:fNC',( C47NT'IACI4F MARY i
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<br /> 15. GENERATOR'SfOFFER4R'S OERTIFICATIBN: I hereby declare that the Wants of this consignment are fullyand accurately described above by the proper shipping name, and are classified, packaged,
<br /> marked and labeledlplacarded, and aro in all respects In propor condition to transport according to applicable fntomafionsiand national governmental regulations. If export shipment and I am the Primary
<br /> Exporter, t canny IN the contents of this coAsignment noptprm to the terms the attached EPA Acknowledgme rbftonsent �
<br /> 1 cartify that the waste minimization statement identified in 40 CFR 282.27( {tf I am a large quantity generate , or {b) �if I am a a)all gJpnaty ens to) is ,
<br /> Can fferor's Prints e� Si nature
<br /> � ] ; g 1 Month 1 Yo 1
<br /> 1B. Inlemaionai Shipments
<br /> F— ❑ Import to U.S. Export from U.S. Pon of entrylexit
<br /> Transporter signature (for exports only): Date leaving U,S;,
<br /> W 17, Transporter Aeimowtedgment of Receipt of Materials
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<br /> Transporter 1 PdnledrT �N me r
<br /> p fF rr Signat to "r' a "" y., �--"' " +s MDnn D ar
<br /> 04 04
<br /> Transporter 4irrintewlypa e
<br /> Signatures M nth Day e
<br /> 18. Discrepancy
<br /> 183. Discrepancy fAdication Space n '
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<br /> t�J Quantity Type ❑ Residue ❑ Partial Rojcdion ❑ Full Rejection
<br /> Manifest eference Number. It
<br /> 18b. Memate Facility (or Generator) U.S. EPA ID Number
<br /> r ;
<br /> Facility's Phone: i
<br /> Liu 18c: % t7reof Altemate FadUfi (or Generator) Month pay Year
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<br /> 19. Hazardous Waste Report Management Method Godes (ie„ codes for hazardo a waste (reamleAt, disposal, and recycling systems)
<br /> 14 z 3 Notice : State of California requires
<br /> generator to photocopy and mail to
<br /> 20. Designated Facility Owner of Operator. Certification of receipt of hazaAdaus m rials ocvored by the manifest except as noted n Ilam 18a DTSC with 30 days:
<br /> Printed ped Name Signature P. tO 8(IX 400
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<br /> Sacramento, CA 95$ 22-0400
<br />( EPA FOrr11870 )w22 (Rev. *17) Previous editionsare obsolete, —
<br /> GENERATOR'S INITIAL COPY
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