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Please print or type. Form Approved. OMB No. 20500039 <br />UNIFORM HAZARDOUS III. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST C A C 0 0 3 1 0 8 7 1 0 1 t ?t ? 533-0112 9226!9295 JJ K <br />5. Goneratots Name and MatifngAddress Att; Tri la pg rEoen s Site Address (H different than maiing address) <br />Huffy Ctmutterce Cotter, LLC ; t t + t . + r` Notty_Porrtmeres Cirri r, LLC <br />231 Lafayette Circle, #200 ,. M .,'.' +' " '2050¢i toli}f Dt1ve <br />Tracy CA 94549 ' `f :� ,� Tra`y;�A 96403 <br />Generators Phone: 9 2 5 2 8 3- 8 7 7 7'd: <br />i. I 1+t' .> >i 41� <br />6. Transporter 1 Compapy Name i ?x �+ y . \ U.S. EPA ID Number <br />7. Transporter 2 Company Name ., , % U.S. EPA ID Number <br />8.De;tgnated Facility Name and Site Address ;r. : r tiftZ•; � tV. V U.S. EPA ID Number <br />W1dd{3WA yq0 SovrN `(vrv.A Cv��*y �+ <br />20130id Alteda <br />G'o ton-ef�-3o Ig536 5 Avs�,v6 +� ,��c0oo506g8O <br />P V V M A AZ $ 5365 <br />Faaltys Phone: <br />gas 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12. Unit 13s Waste Codes <br />HM and Packing Group Of any)) No. Type Quantity WLN01. <br />a 'Non-RCRA Hazardous Waste, Liquid (Oil 8 Water Mixture) 223 <br />0 0 1 Tor G <br />z 2. <br />W <br />L7 <br />3. <br />NNION <br />4. <br />14 Handling 1 ons and Additional inM1q*ation <br />9b.1. — it & Water M30% tura <br />ERG # 171 <br />Invoice Costes Wast•t! Envixonnleti:el, Inc. <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 name, and are classified, packaged, <br />marked and labetedrpiacarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br />I catify that the waste minimmation statement Identified In 40 CFR 262.27(x) (d i am a large quantity generator) or (b) (di am a small quantity generator) is true. <br />Generatoesl08eroes Print edlry Name Signatu Month Day Year <br />J 16. intemauonai Shipments <br />Transporter signature (for exports ontyO Import to U.S. ❑ Export from U.S. —� Port ofentry/exit <br />Date Leaving U.S.: <br />17. TransporterAdOmvAedgment of Receipt of Materials <br />pmpo <br />rtert Pd IekuTT jI <br />IL Name Signatu ; i , Month DayYear <br />-! . irter2Pdn Name SignatureMonth Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy indication Space ❑ quantity ❑ Type ❑ Residue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />1 8b. Alternate Facility (or Generator) U.S. EPAID Number <br />a <br />U <br />,01 Facility's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />3. 4. <br />20. Designated Facility Certification of moetpt of hazardous materials covered by the manife0e0epraknoted In Item 18a <br />nted/ryped Name ' Sign lure Month Oay Ye <br />11 V1 %sook Y11W <br />EPA Form 870022 (Rev. 12.17) Previous edillons are obsolete. ESI NA ED FACILITY TO GENERATOR <br />