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Please orint Or tvoe. Form Approved. OMB No. 2050-0039 GENERATOR I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />C A C 0 0.' : 3 1. 6 2 1 3 1 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />800-624-9136 <br />4. Manifest Tracking <br />022452678 <br />Number <br />JJK <br />Generatofs Name and Mailing Address Att Vebbie‘Oreentan Genegts Site Actdress (if different than mailing address) <br />Hub Ciroup Inc Hu roup Inc <br />2000 Clearwater Drive 1000 E Roth Road <br />Oakbrook IL 60523 French Camp CA 95231 <br />Generator's Phone: . 8. 3 0 9 2 8 2 1 2 2 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />Patriot Environmental Services .. ICADO 5 3 8 6 8 7 9 4 .. <br />Transfierter 2 Co <br />Cl/Vc <br /> <br />puny Name 4 , U.S. E ID Nq.mber <br /> <br />. 0 VL1(.4011 , ( 7\ C- I ;Jo /s-c-ocm L9 <br />Designated Facility Na e and Site Address <br /> <br />U.S. EPA ID Number <br />UftilSby tic Overton <br />1030 W 17th Street <br />Long Beach CA 90813 <br />Facilitys Phone: 562 .4325445 ICADO 2 8 4 0 9 0 1 9 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type QuantityWt.Nol. <br />1non7RCRA Hazardous Waste, Solid (Absorbent and Debris wl residual <br />'Cleaner ." <br />181 <br />solution) <br />0 0 1 DM 00150 P <br /> <br /> <br /> <br />14. Special Handling Instructions and Additional Information <br />Jobg. 11.-21-00531 <br />Profile# 120275 <br />Always wear appropriate PPE when handling waste. JOB# 11-22-00531 <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, aid 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 stat ent identifi in 40 CFR 262 a) (if I ara large quantity generator) or (b) (if I am a small quantity generator) Is true. <br />Generator's/Offerors Printefyld Name ii i (...„) , [..t, a 0 r Signature Month Day Year <br />.--"---- (ft 1,) a tkdr---- ck. e '2,, 0 ' ; ; <br />__I <br />,_ <br />16. Intematio al Shipments Port Export from U.S. of entrylexi <br />Transporter signature (for exports only): ImP°rt t° US. Date leaving U.S.: <br />I.5 17. Transporter Acknowledgment of Receipt of Materials TRANPORTE Transporter 1 Printed/Typed Nai Signature Month Day Year <br />-17 2.4hq -/-i://c? /61,72 <br />"franspo r 2 Intdd/Typed Name Month DaT Year Signature <br />c- Pt L. c.,A,..c-,___ I I O14-1 viz DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br />, <br />Manifest Reference timber: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />\A \ 14 \ <br />2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Pnnted/Type Name <br />' S S 1 Cel <br />Signature Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous editioed are obsolete. ESIGNATED FACILITY TO EPA's e-MANIFEST SY