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III IIII I0108904CLII I III 42324462 <br /> Pleasejpnnt or type. ERI Provider: Clean Earth Form Approved,OMB No.2050-0039 x 1 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I CAL000393335 1 (877)577-2669 200108904CLE <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> (f'Reilly Auto Parts O'Reilly Auto Parts#3810 , <br /> 1651 WEST MAIN STREET 1551 WEST MAIN STREET <br /> RIPON,CA 95366 Ph:4178747257 RIPON,CA 96366 Ph:4178747257 <br /> Generators Phone: <br /> 6.?mnsporter 1 Company Name LLS.EPA ID Number <br /> Clean Earth Specialty Waste Solutions MNS000110924 <br /> 7,transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> General Environmental Mgt,LLC CAD980884193 <br /> 11855 White Rock Road <br /> Rancho Cordova,CA 95742 <br /> Fa Irl Is Phone: 9163510980 s <br /> 92 go.U.S.DOT Descn iton(intruding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(@ any)) No. Type Quanfity WL/Vol. <br /> ad - I.UN1950,Waste Aerosols,Flammable 2.1,ERG#126 214 -Do01 <br /> Qtr ' X 1 CF 00011 P <br /> W <br /> _ 2 <br /> W <br /> 3 <br /> + 4 <br /> 14,Special Handling Instructions and Additional Information <br /> 1n00663(Aemsols,Flammable) <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 Pnmary <br /> _ Exporter,I cei Mat the contents of this consignment conform to the terms of Ih'b attached EPAAclmowledgment of Consent. <br /> I certify that the wase minimization statement identified in 40 CFR 262.27(a)if I am a large quantity genemto)or(b)(fl am a small quantity generator)u true. <br /> Ge rn erors PnntedRype Name,, S are Month Day Year <br /> 1 03 1 22 12022 <br /> 1 . mallonal Shipments <br /> t- Import t .S. El from U.S. of entryleAt <br /> ? i9raporter signature(for exports Doty): Dte leaving U.S.: <br /> IY 17.Transporter Acknowledgment of Receipt of Materials <br /> Trqnsporter 1 PMledfryped Name n um Month Day Year <br /> a Anthony Mack 03 22 2022 <br /> Qi Transporter 2 Pnnted(ryped Name Signature Month Day Year <br /> F <br /> j1&Discrepancy <br /> 182.Discrepancy Indication Space ❑ Quantity - ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection e <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) I N LLC U.S.EPA ID Number <br /> C1 CZRfi���l <br /> LL FatlgysPhone:77S.575. 2760 2°pis IVQvVI S Dry Rg46 r asi NvP9g0 $C1533g <br /> W t6r,„Signature ofNtemate Faulity(or Generator) Month -Day Year <br /> COk-+ tt h t'U <br /> H11.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposah and recycling systems) <br /> 2 3 4 , <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a �. <br /> PrmtedlTyped Name Signature Month Day Year <br /> EPA Form 870422(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />