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2 <br /> Please print or type. —" R - - 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 8 7 F L E <br /> WASTE MANIFEST CAL000393335 1 (877) 577-2669 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 07 Reilly Auto Farts O' Reilly Auto Part s#3810 <br /> 4178747257 1551 WEST MAIN STREET 1551 WEST MAIN STREET <br /> Generators Phone: RIPON CR 95366 11 PON, CR 95366 <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 Genera l Environmental Mgt, LLC U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facility's Phone:9 1635 10980 CAD980884183 <br /> 9a. <br /> 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 Quantity WI.NOI. <br /> X tIN1950, Waste Aerosols, Flammable 2. 1, ERG#126 1 CF 00005 P 214 001 <br /> o — <br /> a ' <br /> z 2. I <br /> cD <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information 1. 1,00663(Aerosols, Flammable) <br /> t <br /> I <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 Iabeledlplacarded,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 EPAAcknowtedgment 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( title small q ge or)is We. <br /> n rdtorsl errors Printed/ryp N(me Si alure Month Day Year <br /> 1 r1 04 101 021 <br /> 1 .International Shipments ❑Import to US. ❑Export in U.S. Port of lrylexi <br /> iDate I vin <br /> ransponer signature(for exports only): <br /> C 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prmted/Typed Name Sig ature Month Day Year <br /> a Anthony Mack 04 01 '021 <br /> QTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ElResidue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: Month Day Year <br /> W 18c.Signature of Allemale Facility(or Generator) <br /> 6 <br /> Z <br /> h 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> O ' <br /> 20.Designated Facility Owner or Operator:Certification Of receipt of hazardous materials covered by the manife ex t as noted in Item 1 a Month Day Year <br /> Pri of ed Name hA <br /> EPA Form 8700-22(Rev.12-10 Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> a7mm—pp 1?v? CAL40000003 541097689 042036526 M PD040121 SD040121 <br />