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800 W. Mossdale Rd. Record ID# PR0514467 <br /> 8/5/2020 Program: HW <br /> Photo 21: The following uniform hazardous waste manifest(018531148JJK) observed with signed copy from designated facility; corrected on site. <br /> t pOoo APPmved.OM6 Na 2056-0039 <br /> Y• - rites 4,ManRas1 Tm5 6Namber <br /> Pi -'not —designed fqr use pnelae_I12 Pam`tf"niter.) 2.Pagel of 3-Emergenq Response Phone ��� �f +1 f 8 1 IK <br /> t Genaralor 14Namber 7. (90Cj 424.83OG 1 1 r}C.Y NIJ <br /> UNIFORM HA2-M1RD0115 - <br /> WASTE MANIFEST C ra LO J 0 21 G4 09 GenetaWfa Site Atldmss Ctl dllfuenl Ihart malting address) <br /> 5.Genemrers name and Mallmg Adhrese <br /> FROWN SAND INC <br /> P 0.Box 129 CA 9533D g0O W.N)QSSbiLE RD CA 95330 <br /> tCTHAOf' 209 a�00c6 LATHROP <br /> Genemlors Phone. U S.EPA IP Number <br /> e,Tmmpaner l Cempeay Name CAI]0 2 9 2 7 7038 <br /> tYORLO 6fL ENV RONMCNTAL SERMES u.s.EPAIo Namder <br /> Tmn z ComPe V NameI C t4 R O 0 017 5 4 2 2 <br /> 1':Jr~.ID1s10t m[(.•oYERIy S1t37 EIYY IN's. U.S.EPA 19 Ndmber <br /> a-DesgnaEeO Fatllily Name and SlreAddmsaU.-.12 Viormtes End Insen-It <br /> NT' <br /> 0900 M 1%HWAY 95 <br /> WNLA AZ a5365 AZR000521146 <br /> F-W-Phone �a 10.Comair— 11.7.W 12.and 13.Waste Codec <br /> an.u.S.OOT Gesrnptinn(tndudlre Fmper Shlppi%Name,Barad ansa,ID Number. O—Uty WLAfoI. <br /> IiM and Pea"Gmep(e-0) Na. TY� ' <br /> %;,.q-RCCA HAWD005 WASTE.SOLID(PAKR FILTERS) _ 2 <br /> I <br /> • r• <br /> 2 2. <br /> 3. <br /> 14 5 spat Nanaimg Inswkions aMa+dditional InraTnadort <br /> EtdERGENCY coumCT:CHEMTREC 1-6004249300 WOES TERMINAL:CERES CS "Pf2OF1LE k Si.2:162623880095 PAPER <br /> flLTERS.r-*ArPMPRJATEPPEEQU1Pir4@Ni__.. <br /> i <br /> T5, GENERATORVOFFEROR'S CERTIFICATION.i heiebydedare th.tthe conlerds o[tlas mnsignlrre+it are IdI1V and accuratety described above W the pmpar shipping name.ab are r3assiaad.P Sed. IPgUP <br /> marked and tabeledipfacarded,and are in all—Peds in proper condllian for trampod according to applicable inlernabonal and nafmnal govemmankl gula4uns.a ekpon shipment and I am the Fn—r <br /> E,W,aj,,Icerdy inat the c menta ar this—gnmenl—r—W the tamed the anached EPAAcFnowerawr)wlmonn-rdof CAiInn <br /> I nerdy that the waste min miLoon atatanenl identaed in 40 CFR 262.211.){it l am a large quantity ganeratnr}or Ibl Crfl am a,snr.4 quantify generator}k hoe. <br /> • slgltatum�1 Mon1h OaY YraCar <br /> Ganemmew0fs mr5PdnleNTYped Narita I r <br /> J 16.Intematlonal Shipmenra ❑lml M U.S. ❑Expua aom U.S. � �Port�f entryledd — <br /> Oa{e ifleNng U.S.: <br /> 7 nsportar signatura(lor expods ontyl' <br /> w 17,Transp�rterAcPnnwledgrmddRedaiptdMaler�s_ <br /> ElgneWm -{(a-!, Month Day Year <br /> Transpoderl na[?ypadN mea r f. r�`f11/a �� .f (�d ff(('Jfl `-'�L-( j --i <br /> f� � t V5_ltf•1 I <br /> t. T Manch Day Year <br /> 4 rrafn;apoaer2PdnWyped Name 1 SigneWre <br /> Ui 1.stcc�c„rl I a <br /> • 1B.Dlacrepartcy <br /> 1111 18.Disonmancy Indkmhco Spam Cwli* ❑TVP• ❑Residua 411, ❑Partial Refection ❑FuN Re eu on <br /> Manfred Reference Number, <br /> IBa.Anemata Fatuity lw Generator) U.S.EPAIDNumber <br /> J <br /> U <br /> a4i Facdifps Phone: <br /> w Ids.Signature crAkemale Fadllty(or Generatodj Month Day Year <br /> I <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(l,e.,mdes for harardous waste treatment,6sposal,and recycling syllems) t <br /> 2. <br /> LU <br /> c <br /> 26,Designated Fad ly Owner or Operator:Cediraatlon of receipt of hazaldaus maleiial9 covered by the manileat except as nded in Item 1 Ba <br /> PrinledRype me Signature 1 w r t Day Yar <br /> f'�il�l7f r 1 <br /> EPA Form 8700-22(Rev 3-05)Previous edltiorts are obsolete. `J It ,ESIGNATED FACILITY TO GENERATOR <br /> JASON GAITAN, EHS Page 21 of 21 <br />