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Jan 04 22 01 : 27p Payless Auto Repair 209 -334-3115 p , 1 <br /> Please print or type. Form Approved, OMB No. 205M039 <br /> UNIFORM HAZARDOUS 1 . .Gene a'or ID Number 2. Page 1 of 3, Emergency Response Phone 0. ManffestTracking Number v <br /> WASTE MANIFEST 1 ; : i . .r r+ a '. JJ <br /> 1 14 <br /> 5, Generator's Name and Malting Address Generator's SAe Address ( t different than mailing address) <br /> y <br /> ry <br /> Generator's Phone: i - <br /> 6. Transporter 1 Company Name1 . U.S. EPA ID Number <br /> 7. Trenspoder 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number : • • • .• <br /> Facilil¢s Phone : <br /> gar &b, U.S. DOT Description (Includvig Proper Shipping Name, Hazard Class, ID Numbar, 10. Containers 11 . Total 12, Unit <br /> HM and Paddng Group (•r any) ) No. Type Quantity WiNd. 13. Waste Codes <br /> 1 . 41 _ . . . <br /> Lu <br /> 2. i <br /> C9 ! <br /> 31 r <br /> t <br /> 4. <br /> td. Special Handling freUudons and Additional Information <br /> . . <br /> 15, GENERATOR'SIOPFEROR'S CERTIFICATION: I herebydeclare drat the contents of this consignment are fully and accurately described--above by the xoper shipping name, and are �assililed, packaged, <br /> marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations. I' export shipment and i am the Primary <br /> Exporter, I Certify that the contents of Ill consignment conform to the terms of the attached EPAAcknowledgmeit of Consent <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (II I am a large quantilygenerato_) or (b) (dl am a small quantity generator) s true. <br /> Generator'sfOfleroe4s Printed/Typed Nqme : Signature . . P.riCnlb Day Year <br /> W . n CIf <br /> 16, International Shipments <br /> i- ❑ Irrport to U.S. ❑ Export from U.S. Port of eniry,`exit <br /> Z. Transporter signature (for exports only); <br /> Date leaving U.S.; <br /> IX W f7. Transporter Acknowledgment o4RecelptofMaterials <br /> -ransporier 1 Printed/Typed Name Signature Month Day Year <br /> p - r .. 1 # <br /> am F <br /> Z Transporter 2 Printetl/Typed Name <br /> Signature Month Day Year <br /> F- <br /> ' 8, Discrepancy <br /> 89 . Discrepancy Indication Space OuartlftyElType ❑ Resdue <br /> Fart at Rejection ❑ Full Rejection <br /> Manifest Reference Number, <br /> 18b. Aftemete Facility (or Generator) U.S . EPA ID Number <br /> J <br /> V <br /> Lt.' racritys Phone: <br /> w 18c. S gnature of Alternate Facility ;or Generator) Month Day Year <br /> a <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes for Nzardous waste treatment, disposal, and recycling systems) <br /> C3 <br /> P1 % RFD <br /> 20, Designated Facility •Jwnor or Operator; Certification of rece'ptof hazardous materiars coveree by the manifest except as need in Item iBa <br /> PrintediTyped Name Signature Month Day Year <br /> DEC 2 9 2021 <br /> EPA Form 870C-22 (Rev. 12.17) Previous editions are obsolete. FGE=NERATOR'S INITIAL COPY <br /> ENVIRONMENTAL HEALTH <br /> 0rPAPTMENT . . _ _ . . . . . . . . _ _ . . .. . _ . . . - <br />