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111111111111111 Form Approved.OMB No.2050-0039 <br /> Please print or type. R : pp <br /> Eart <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track' Number <br /> WASTE MANIFEST CAL000392478 _P,- 015 01703 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> O' Reilly Auto Parts O' Reilly Auto Parts#2567 <br /> 4178747257 1440 EAST HARDING WAY 1440 EAST HARDING WAY <br /> Generator's Phone: STOCKTON CA 95205 ST CIS <br /> CA 95209 <br /> U.S. PA ID Number <br /> 6.Transporter 1 Company Name <br /> Clean Earth Specialty Waste So utions <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21st Century EMN, LLC <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone: 7755752760 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> X 1UN3264, Waste Corrosive liquid, acidic, 1 CF 00004 P L79 D002) <br /> of inorganic, n. o.s. (Phoshoric Acid, <br /> 9 Hydrofluoric Acid) 8 PG II ERG"17!1 <br /> Z 2-Non-Hazardous, Non-Regulated Solids i CF 00013 P 18Y <br /> 0 Sulfuric Acid), <br /> 3. <br /> 4. <br /> ( <br /> t <br /> 14.Special Handling Instructions and 11 Additional Information 1. 100667(Corrosive Acidic Liquid) 2. 112336(Soda Ash with <br /> Battery Acid) <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 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. `. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or"smallqur)is true. Month Day Year <br /> Generator'slOfferor's PrintedlTyped ameSignature16.Internationa hipments Impo U.S. Export from U.S. <br /> ZDate leaving U.S.: <br /> Transporter signature(for exports only): <br /> P!17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> Transporter 1 Printed/Typed Name Signature <br /> 03 30 202 <br /> a John Lain <br /> Z Transporter 2 PrintedlTyped Name <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space quantity Type <br /> ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> F 18b.Alternate Facility(or Generator) <br /> J <br /> QMonth Day Year <br /> ri Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems 4 <br /> LU G 1. 2. �/ <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest <br /> natueecept as noted in Item 18a Month Day Year <br /> Signature Printed/Typed Name / C A " �\ <br /> EPA Form 8700-22(Rev.12-17) Previous e/ddiitio•nns are obsolete. f U DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 8700-22 12v3 CAL40000003 S41097203 042036596 M PD03302.1 SD033021 <br />