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Please Print 0 V.rtor <br /> 0 rp.9terizi n nag OC7,utntd Q*l ti�-_e <br /> ,Z -,:`"V A)O�MV;�.it No.2050.0039 <br /> 1--_ <br /> UNIFORM HAZARDOUS I Generator 1D Number 2-Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST L-A 10 Q 0 S 1. 7 5 1.4 i 48 3-3-1 fj 1 0-1479.6289 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address i(if different than mailing address) <br /> 41A4 Ma <br /> V" 53 A M E <br /> GA6oANA,Cjl 952043 <br /> ill rQ <br /> 6.Transporter 1 Co It- <br /> rhoril U.S.EPA I D Number <br /> Clean Harhnr5 Fnvirnaingtilat.1;pt%tjr,;Kg <br /> W A R .; 4-�P 2 24 Z 4,� <br /> 7.Transporter 2 Company Name U.S.EPAtD N ibr - <br /> 8.Designated Facility Name and Site Address U S.EPA ID Number <br /> arboill Jose LLC <br /> A M ILI n A <br /> 1021 Senvessa Road -_e _T 9 4 3 10 <br /> CA 95133 <br /> fill Q&4 4 4: 0462 <br /> 9a, 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number., 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If any)) No. Type Quantity Ntjvol. 13,Waste Codes <br /> 1. <br /> UNi993,WA-M FLAMMABLE UQUIDS,Ill(DIESEL. <br /> 0 <br /> X GASOLINE1.3.PFj It PM <br /> Ell <br /> 2. <br /> 0 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> 4 <br /> CH3 71-5 10 -ERG#1-2 5 )c S:Y C,"wow-1 <br /> Ftp <br /> Cvilr'.n�l ri2t3llmio;t-i,qm_iier-iy," <br /> 15. 6ENERATOR'S1t7FFEft�R'S CERTIFICA ION: Xere y 3e'clare that ifie contents oftFiis co isigEiinerit are idly olid ado Y, <br /> marked and laboled1placarded,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 he waste minimization statement identified in 40 CFR 262.27(a)Of I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Gerieralicies/Offe r' P' /17,ped Name Signature Month Day Year <br /> Ill;I M <br /> 16.Iniornalloral 5n[l <br /> ❑Import to U.S. ❑Export from U.S. Port of eriq/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> tE Transporter 1 ProtedlTyped Name Signature Month Day Year <br /> 0 c1�11.-al <br /> a- <br /> A L <br /> � Transporter 2 PrlritediTyped Name Signature Month Day yaar <br /> 18.Discrepancy <br /> 1l Discrepancy Indication Space ❑ Quantity ❑Ty'. ❑l ❑Partial Refection ❑FUI l <br /> Manifest Reference Number <br /> 1 Faclkv'or-eirter3tcr' <br /> U_ Facility's Phone! <br /> Uj <br /> 18c.Signature of Alternate Facility(or Generator) Mcnih Day Year <br /> !� <br /> Z <br /> 0 <br /> M 19.Hlazardcus'Nasis l Management Metricd Codes(i e,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2. <br /> 3. 4. <br /> ' H144. I I I <br /> K Designated Facility Ovmer or Ol Certification of receipt of hazardous materials covered by the Manifest except as icted in Item 15a <br /> _ 777Name Signature Ml Day Year <br /> EPA Form 9700-22 i'Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's a-MANIFEST SYSTEM <br /> -4 .a-- 2ppo 4-r-ale l;tr 3,, *ji,3ccepl me #3 5t? <br /> 2 <br />