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Please print or type <br />unii-oRM HAZARDOUS I Generator IL) Number 2 Page 1 Form Approvod. OMB No. 2050-0039 <br />WASTE MANIFEST <br />5 Generator's Name and Mailing Address <br />of 3. Emergency Response Phone <br />Generator's <br />4. Manifest Tracking Number <br />016996500 FLE <br />Site Address id different than mailing address) ceslifted Freight Logistics <br />Hied Freight L4sti?t 1344 VVhile Court 3 . 20224, -121.52048 Santa Marla, CA 23450 Tracy, CA us3n Generators Phone <br />6 Transporter 1 Company Name <br />A U S EPA ID Number ll Ernironmental Senices LLD <br />I CAL000421863 7. Transporter 2 Company Name <br />U S. EPA ID Number Atlas En4ronmental Solutions <br />I CAR000295220 <br />B Dssqvated Fa li' tj Nagle aryl Site Adllies,s <br />Ernironni antal Waste Solutions, Inc. U.S EPA ID Number <br />31915 Industrial Lane <br />Raker South, A2 8..5344 A212000520478 <br />Facility's Phone! <br />Oa 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11. Total 12. Unit HM Packing Group and tif any)) No Type Quantity ZA.Noi, 13. Waste Codes <br />' NonRCRA Hazardous Waste, Solid (ABSORBENT, DIESEL) 352 <br />2 Non-RCRA Hazadous Waste, Liquid <br />OM 5-c) 223 <br />14, Special Handling instructions and Additional Information Document. uo,J257u- <br />1) EWS 2) EVVS <br />BI to At -* 15 GENERATOR'SiOFFEROR'S CERTIFICATION! I hereby declare that the contents of this consignment are fully and accurafely described above by the proper shipping name, aid are dassfred, packaged. <br />marked and labe!ed'placarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 ...taste minimization statement Identified in 40 CFR 262 27(a) (if lam a large quantity generator) or (b) (if 141011.17-y generator) is true Gene, s 0r. Pnnt diTiiir N e / Signal Month Day Year <br />V <br />International St !TRANSPORTER I N11 pments <br />Ill Import IOU S 0 Export from US. Port of entry:exit kgnalure porter (fcr exports only)! <br />Dale leaving US : <br />17 Transporter Acknowledgment of Receipt ol Materia!s <br />Tran Pn fed -.digill.P. rt d Nam <br />) <br />Signature ......000001111111111111111111111800"-- Month Day Year <br />° IIWZ Transponer 2 Printed/Typed Name gnalure Month Day Year <br />18 Discrepancy .1 <br />18a Discrepancy Indication Space <br />Quanity LII Type Residue LI] <br />Manifest Reference Number <br />. Partial Rejection Full Rejection <br />180 <br />7, <br />03 <br />a u_ <br />j.9 <br />Aiternate Facility rer Generator) U.S EPA ID Number <br />Facilitis Phone <br />1— < <br />16c. Signature <br />z <br /> <br /> <br />ofpiternale. Faority (or Generator) Month Day Year <br />Cl) 19. Haza rdous Waste Report Management Method Codes (lo , codes for hazardous waste treatment, disposal, and recycling systems) <br />1811. <br />' <br />2 3. 4. <br />120. Designated Facility rm or Operator: Certification of receipt of hazardous materials covered by the manifest except as wed In item 18a I ()a <br />7,MtlIt(1111t3 <br />Monet Day Year <br />EPA Form 8700-22 (Rev. 12.17) Previous editions are obsolete. 1 1 <br />DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />tn <br />r/tof 6-D -12io1Yr) ?.iwi 00 r,1 Ect) rs 0 ( ALL 0\hittor-1 mtr\frA-1--) \TI tyyk 01,) <br />N 1-14 2-) -