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r <br /> Please print or type. 200222050CLE 42434170 <br /> ERI Provider:Clean Earth Form Approved.OMB No.2050-0039: - <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000392478 1 1(877)577-2669 200222050CLE <br /> 5.Generator's Name and Mailing Addressb <br /> Generator's Site Address(if different than mailing address) <br /> O'Reilly Auto Parts O'Reilly Auto Parts#2567 ` <br /> 1440 EAST HARDING WAY 1440 EAST HARDING WAY <br /> STOCKTON,CA 95205 Ph:4178747257 STOCKTON,CA 95205 Ph:4178747257 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Earth Specialty Waste Solutions MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> 21st Century EMN,LLC U.S.EPA ID Number <br /> NVD980895338 <br /> 2095 Newlands Dr.East <br /> Fernley,NV 89408 <br /> Facilit es Phone: 7755752760 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> 1•UNI 950,Waste Aerosols,Flammable 2.1,ERG#126 <br /> OX 214 13001 <br /> 1-- 1 1 CF 00027 P _ �•a <br /> Z 2. <br /> LU <br /> 3. ` <br /> 4. � . <br /> 14.Special Handling Instructions and Additional Information `s <br /> 1.100663(Aerosols,Flammable) <br /> 15. GENERATOR'S/OFFEROR'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 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the.attached EPA Acknowledgment of Consent.. j <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a sr9pillouantity generator)is true. <br /> Generators/Offerors Printeki/TypednNam�e, Signature I Month Day Year <br /> J 16.International Shipments 08 102022 <br /> H ❑Import to U.S. ❑Export from U.S. Port(le <br /> en !exit: <br /> ? Transporter signature(for exports only): Date ung U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Transporter 1 Printedlryped Name Signature Month Day Year �~ <br /> N Trent Pittman 08 10 12022 <br /> Transporter 2 Printed/Typed Name <br /> Signakn Month Day Year • <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space t <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> # <br /> 18b.AManifest-Reference Facility(or Generator) Reference Number: <br /> _ U.S.EPA 10 Number t <br /> J <br /> C ',. <br /> Facility's Phone: <br /> Signature of Alternate Facility <br /> t <br /> Q 18c.Si 9 ty(or Generator) Month Day Year � <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)LU ` <br /> 1. 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18ar ') e <br /> t <br /> PnntedlTyped Name ' Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.12 7) Previous editions are Nolete. <br /> DESIGNATED F ILITY TO EPA's e-MANIFES SYSTEM <br />