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06 / 11 / 2021 1 : 59 Phi FAX 2099488625 AHCE SAW 0001 / 0004
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<br /> PleLaiage print;ar type. Form roved, OMB No, 2050-0039
<br /> UNIFORM HAZARDOUS 7 . Generator ID Number 2, Paga 1' of ,3. Emargsncy Response Phone d. Ma006148405
<br /> ^rtglfa§5�l Trac ng Number }' /'+ p t
<br /> WASTE MANIFEST CAL00017 iA t �9t)i9�;t4044�49 Ili 0 4 8 4 0 GBF t
<br /> 5. Generator's Name and Mooing Address Generator's site Address (Irdifferentthan maaing address)
<br /> At; Ar:oSA fl!
<br /> PM 1204, l� MAIN S'['
<br /> f�1't�ol(riON , CA 95020
<br /> Generator's Phon r�. _ r 3 IJ.S, EPA ID Number
<br /> e. Transporter 1 company Name
<br /> AWiERIC,AI'4 VAIIl :'1' WAI`LR 0ILI I N0, �fAFtt7�lf i2"l;:�)2
<br /> 7, Transporter 2 company Name U.S. EPA ID Number
<br /> �,Ti:IittrYl .k, 'ltafrQ)FA1If14VAsloi; SOLL; R0N$ J14 $ i<&CH3[lT1t39 �=}
<br /> S. Designated Facility Name and Site Address U,S, EPA ID Number
<br /> �IvMF3Af+tir'th:1 �>iit)iJlfF�, I,t�4 , i~{i.Ci:£tf5Qc�13+lit}=�
<br /> 1 1859IW41 itf IHIOrE Ro� ;K Rte,
<br /> FACIG s
<br /> 98 8b. U.S. DDT Description (Inrduding Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes
<br /> HM and Padang Group (tf any)) No, Type Quantity WIJUoi.
<br /> 1 , tat�frl f�t�•ttI s;', t
<br /> f2 �7 tlda 'I {rcj;L tNA 'r Fi. AP�P/thLaLl I.1CRftl')�:, 1�3. 4) . . , t}!ytt , ( VA 1 0000 Gi
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<br /> MWL
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<br /> 4.
<br /> 14. Special Handing Irtstructtons and Additional Inromtatfon
<br /> urzr�sr�ft�� �r3+�� r�ta3 +:N1;� , Crlk. a:tr` c3f� 3 �S
<br /> ENIL.rRGIEtVL Y C0WAC'f': MIARY
<br /> 15, GENERATOR%1OFFEROR'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 labeledlplacarded, and are in all respects In proper condition for transport according to applicable intemabo0al and national,govemmentel regWatiens. if export shipment and I am the Primary .
<br /> Exporter, I carttfy that the cohtonts of this Consignment cantor to ft terms of the attached EPAAftowIMgtrielll Of Corisept. , i .
<br /> t certify that the wastemintmlzation statement identified in 44 CFR 26227(a) (if 1 am targe quantlry generator) or ' h) ('dam a small quar�tiry genetor) isinue. ;.I
<br /> 00000
<br /> Go»eratoes1O etor' Printed1r46
<br /> , d Na 9 Signature r i Mogth Days Y6at�
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<br /> 16, Int,%motional Shipments EJ import to U.S. ❑ Export from U.S. Port of entrylexh; 4
<br /> Transporter signature (tor exports only): Date leaving U.S.:
<br /> W 17. Transporter Acknowledgment ofReceiptofMaterials
<br /> FW— Tr nsporter, file ed Nama r Signet tem =" ��f M"" ° - ';x '� -- '" Mo Da Y
<br /> a rr° � �;. ._ oovter,
<br /> aa I 00000dt,pl door
<br /> T orter2 Pdntedryped Narne w ^ Sfgnair7re" '' MofiUt Day «fee
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<br /> 18, Discrepancy
<br /> 18s. Dfscrapancy lndloation Space ❑ ouandty ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full ReiectlOn
<br /> Manifest Reference Number.
<br /> lab, Alternate Facility (or Generator) U.S. EPA ID Number
<br /> v
<br /> Facility's Phone, Month Day Year
<br /> Signature of Attemate Facility (or Generator)
<br /> 19, Hazardous Waste Report Management Method codon (he., codes for hazardous waste treatment, disposal, and recycfino systems)
<br /> -. ..
<br /> . 1 . z. a. Notice; State of California requires
<br /> generator to Photocopy and mail to
<br /> 20. Designated Facility Owner or Operator Ceftificallon of receipt of hazardous materials covered by the manifest except as noted in Item 15a 0TSC with 30 daysi
<br /> Printed/Typed Name Signature PLO Box 400
<br /> Sacramento, CA 95812-0400
<br /> EPA Form 8700-22 (Rev, 1247) Previous editions are obsolete, d GPERATOR'$ IN COPY
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