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Please print or type. V <br /> UNIFORM HAZARDOUS 1. Generator ID Number Form Approved. OMB No, 0039 <br /> IE,I10001300b2 2. Page t of 3, Emergency Response Ptwne 40 ni st {a n be <br /> WASTE MANIFEST 800-42"-� 0� 2 . G B F <br /> S. GeneratorsNam Q �ndr' II A�ddwe � tal Clean ' LLC Generators IIeAd ress I dig lO jib n addross <br /> 1175 Point E;Ivd. Ste 375 I�erl�ag� - � r�rs�a'Y� �ean , LLC <br /> Elgin , IL 150123 4370 Absolut Avenue <br /> t?7317-79�Itf <br /> Generator's Phone: Fresno, CAI 93725 <br /> i ' <br /> 6. Transporter 1 CDme <br /> pra Rabe - Crystal Clean, Inc. U,S, EPAIDNumber <br /> 7. Transporter 2 Company Name ILR00010300152 <br /> U.S. EPA ID Number <br /> 8. Oesignatod F0G11tvN���d S taAdtoss <br /> �li +1Oag11I11, LLC <br /> WW tt7x�U1 U.S.7EPA ID Number <br /> 14287 E. Manning Ave <br /> Parlier, CA 936413 55s,��s-0240 <br /> Facility's Phone: CAL000102751 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> HM and Packing Group Colony)) 10. Containers 11. Total 12. Unit 13. Waste Codes <br /> 1. Na Type Quantity W0101. <br /> Noll RCRA t-lazarclouS Waste, Liquid, (lased , oil l nixed oil TT 221 <br /> W 2. <br /> Oil! <br /> q � <br /> 4, <br /> 14, Spel lipg�s�tr r�r sa dA(Ediiionai lgjor�liWill Will III till 11 11 <br /> on <br /> 1 Y�v b. 3) <br /> Db. 2) <br /> . b.h) <br /> 11 MEN III III Will IIIIIIII <br /> 15. GEN ERATOR'SiOFFEROR'S CERTIFICATION: I hereby declare that the cAntents of this consignment are fuily and accurately described above by theroershi and are dassified, packaged, <br /> marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable international and national, governmental regulations, f export shipment and I am the primary <br /> Exporter, I certify that the contents of this consignment conform to ti terms of the attached EPAAcknowiedgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity general F <br /> nerator• 8eroe Prinled/1y ped a ( gone t <br /> ignaiure th Day Year, <br /> � <br /> 166 I omalionamon <br /> i Shipls <br /> ❑ Import to U,$, ❑ Export from U.S. _ pori of enfrylexjl <br /> Transporter signaturo (for exports oty): <br /> X <br /> 17. Trans derAcknowledgment of Receipt of Materials' Oate leaving U,S,: <br /> ra'sCmy�� — <br /> O Si I <br /> M Month Day Year <br /> h nsporter 2 Pdntod/fyped Name 130 <br /> Snature Month Day Year <br /> 18. Discrepancy <br /> 181 Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> 18b. Alternate Facility (or Genurator) Manifest Reference Number. <br /> v <br /> U.S EPA ID Number <br /> Facility's Phone: <br /> W 18c. Signature ol'ABemate Feclity (orGanemlor) <br /> 4 ' <br /> � <br /> Month Da y Year <br /> liiiiiiiiiiiiii till <br /> U3 19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste troatin Will <br /> dfsp11salo and recycling systems) <br /> 1' 2. <br /> 3. Aliiiiiiiiiiiii MINIMUM <br /> 20. esignalod Facility Owner or Oporalor Certlgcation of receipt of hazardous materials covered by the manirest except as noted b Item <br /> Prinled/Typed Name 18a <br /> Signature Month Day Year <br /> EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolote. <br /> nr&.gIi"alnTrnVnrnrrrilir. "m ,. . _ . - li ,i _. . <br />