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800 W. Mossdale Rd. Record ID# PR0514467 <br /> 8/5/2020 Program: HW <br /> Photo 20: The following uniform hazardous waste manifest(0 1 6769299JJK) observed with signed copy from designated facility; corrected on site. <br /> Please Print urlype.(Form de,Sgmd for use on elite(12phtlr))pewriter} <br /> UNIFORM! Number - z.Page lel 3 Emarseray Rmparne PMne <br /> WA¢S�TTE�gM�Ai�N[nIF�EySIgTya]�upedC�SAg�L�Q 0 8 2 18 4 0 9 1 (BOOj 4248.M <br /> 5 GanGfiUWR.YIv1U 1f4S� O1tVVBS Ctirieraw(s Stle Admess fadiflerenl Nei <br /> P 0 Box 1129 <br /> LATHROP CA 95330 800 W MOSSUALE RD <br /> Generetars Ph— 209 321.0046 LATHROP <br /> e.Trainpp�°.rlert iry Name uS CFAID0 <br /> WORLG1 ENVIRONMENTAL SERVICES <br /> 7mncpaRer 2 C«^Pam1 Name a s.EPA 10 Numbs <br /> A.nesigreled FaWi Namee^CSde Adtlresa <br /> US.EPAte Number <br /> us ECOL�Gr VERNON INC <br /> .>• 5375 9011TH BOYLE AVENUE <br /> LOS ANGELES CA 90056 C A 0 0 9 7 0 3 0 <br /> Feali sPiSme: (323)27 I-LSOU <br /> 32S 77-1.500 <br /> 10 ca^€s;ners 11.1dal 12.and <br /> 4a and PN cDOT,,VG mPa°dfmdudlt•3 Prq'9r ShiPP1^9 Name,HaraN Cleea,Ip Norther a—Uy WI.N01 53, <br /> NR andPacNingGmupfda^Yb No TyPe <br /> 4I NON-RCRA HAZAR00US WASTE.SOLID(GREASE) 352 <br /> .a P - <br /> o O M <br /> LK <br /> rc <br /> - z 2 <br /> WU <br /> 3 <br /> 4. <br /> A <br /> 14.syedm Nanaling tnsW^doP:and Addiponal Inmrmamn L.E M 9B3: <br /> EMERGENCY CONTACT:CHEMTREC 1.800424-9300 WOES TERMINAL:CERE9 q N'fI4ERGM 981:17 a y <br /> _,90687 GREA4E•IP60040094402"APPROPRIATE PPE EQUIPMENT �\ <br /> 15. GENERATOR'SfCFFEROR'e CERTiFIfaTION:Thereby declare fhatlhe mnlanis of mis consignmencerefully antl eccwalely tlesnitxd above by lhepmpersnipping^ania,and are dass4ed,packaged, <br /> markedand R'SfCFFEROReS5^dare Inadme; hinyd.1co"d'hon forVanepaRaaording to aplNirableintematiorlal and natio^sl9°edmmantal reguWlYons.If expos snlpmenl alta1am the Pdmery <br /> Exporter,l oemry that the panteats nrfMs mnsignmenl norrfam te>ne terms otdre athed EPAA°kn°wledgme^I°(Ch1 amMasmart quantity genaml«}is we <br /> Icerotyma[Ihe waste mwmlzatlon arakanent idensfietl in 40 CFR 2622Yfa}{ifl am aiaye quantity ge^eralPr}or(ti1Q „e, pay Year <br /> G'gPatum �„2 / <br /> Generals Pn ra�f7slOAeeR/Y��etl Name ,/ (J!� <br /> X /-J F YI{'x x Port en lexlt: <br /> - 16Jmamahonat Shipments ❑Import W u 5 ❑Expan eom U.5 aY <br /> F Date leaving U.S.'. <br /> Z Traneporler slgnamreffor exports°nN}: <br /> 17.7ranspodarAcknox4edgmantofRereNl of Malefla5 Signature Mnn01 Day Year <br /> w u <br /> Tran r 1 PdnielUTyped Name m <br /> � LLI 1/r.[/�t•�`f `� `•`T Month Day 'fear <br /> ' a Signature <br /> Transporler2pm,10yped Name <br /> 4 <br /> F <br /> ♦ 19.Diserepaacy <br /> I 19x.Oiscrepanq Indica0o^ Quantity Space ❑Type ❑Residue ❑PaNeV Rejection FuA ReyeclVon <br /> ❑ <br /> Manifest Relarence Number- <br /> U.S.EPAlO Number <br /> 18h Allemafe Facility(w Generarorj <br /> J <br /> U <br /> if FavAty'5 Phone: Month Day Y0a1 <br /> ISc.5lgnalure afAiremale Facility ter Generalorp <br /> 4 <br /> 2 <br /> Hazardous Waste Report Management Method Codes(LB-,codas for hazardous wade treatment,tllsDosal,and recycling syslams <br /> LI I. ' 2- 3 4, <br /> 2d,Designated Facility owner or Operator.CeNhcation of recelptel hazardous materials covered by the manifest except a$ndsd In Orn 1Ea <br /> FnmeNryped Mame Signature fAanfi Oay <br /> EPA Form 8700-22(Rev.3.05) revious editions are obsolete DESIGNATED <br /> JASON GAITAN, EHS Page 20 of 21 <br />