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Please print or type. 111111111111111 <br /> UNIFORM HC Ip 1.GeneratNu <br /> AZRROOUS her 2.Pane 1 of 3.Erno gency Response Phnns 4.Manifest Tracking umberoved.OMB No.2054-0039 <br /> WASTE MANIFEST <br /> S.Generators Name and Maifing Address a 0 40 ��ry�C C L C <br /> Generalors Site Address(if different than mailing address) v V i C <br /> �1?p Boys #Sb2 <br /> Pep Boys#!362 <br /> 1.`�01 S Cherokee Ln <br /> enanspo r1 Ca 1401 S Chelit"O�eC, Ln <br /> ti.Transporter 1 Company Name <br /> 3 <br /> f .EPR#0 <br /> 7.Transporfer2 @ AEOIci <br /> y a5 a C1 + "1[it5 fly <br /> H.Designated Facility Name and S to Adtlress <br /> Genet-al Environ#F?ntalU.S.EPA ID Number <br /> 11855 White Rock Reath s � <br /> FaciiirysPhane: Rancho Cordova, CA 9574.2 <br /> 9a. 9b.U,S. ding Proper Shipping Name,Hazard Class,l0 Number, <br /> HM and Packing Group(if any)) 10.Containers o a- -6 <br /> 1. No. Type Quantity ii t al. 13.Waste Codes <br /> aX N1950, Waste Aerosols, IfiamNable, (each not <br /> exceeding 1 L, capacity)] 2. 1, ERG#12B CF ����� � _�y � <br /> LU — -- <br /> c� <br /> 1 I <br /> 3. <br /> t <br /> 4, v <br /> t <br /> I <br /> 14.Special Handling Instructions and Additional information <br /> 1.78375(Aerosols, Flammable) <br /> 15, GE ked and R'S1DFfER4R'5 CERTfFICATlON: !hereby declare Ehat the contents of this consignment are fully and accurately described above by fhe proper shipping name,arrf aro classified,packaged, <br /> marked and tabeie at the <br /> Gon and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If ex ori shi went and I am the Primary <br /> Expo ter,!sa t fy that the contents of his consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimizat#on statement identified In 40 CPR 2G2.27(a)(if I am a large quantify gor ' <br /> GeneratatslDfferors Rfinted Typed Name enerat }or 1b)(ifl all quantity ge r)is true, <br /> c�� 7 ��r, 1 � Signatu <br /> Mo Day Year <br /> _.r 16. rnational Shipments <br /> } LJ Impart to U.S. <br /> ? Transporter signature—exparts- .} Export from Per,of entrylexit:_ <br /> y: <br /> Ex 17,Transporter Aetcrawledgment of Receipt o{Malarials Date leaving U.S.: <br /> Transporter 1 printed typed Name <br /> CL <br /> Sign ' <br /> W r Pr Month Day Year <br /> a, a <br /> ignature m <br /> on ay r <br /> 18.Discropancy <br /> 18a,Discrepancy Indication Space ❑ <br /> ❑ Quan4ty T <br /> yf. ❑Residue ❑Partial Rejection ❑Full Rejection, <br /> 18b_Alternate Facility(or Generator) I tan#est Reference Numbec <br /> =t <br /> U U.S.EPA ID fvumber <br /> + Facility's Phone: <br /> Lui 18v.Signature of Altemate Facty(or Generator} <br /> !R <br /> Q <br /> 2 Month Day Year <br /> tJ5 1.19.Hazardous Waste Report Managemenl Method Codes(i.e.,codes for hazardous waste Treatment,disposal,and recycling systems) <br /> © 2. <br /> 3. <br /> 4. <br /> 20.Designated Facility Owner or C. tor:Cenificalian of receipt of hazardous materials Covered by the mantle, noted in <br /> PrintedrType;f Name 1 <br /> r110 gnature <br /> Month Da Year <br /> EPA Fom1&700-22(Rev.12-37) revious edi ons are obsolete. <br /> '%, <br /> 8700-22 1223 CA200BLA057 5111:17 nAtCc..-ic, .. <br />