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06 / 11 / 2021 1 : 35 PM FAX 2099488625 AMCE SAW 0002 / 0007
<br /> Please pht or 1 pe- Form Approved. OMB No, M0030
<br /> UNIFORM HAZARDOUS1 . Generator IG Number 2. Page 1 cf 9, Emergency Response Phone 4, Manifest Tracking Number
<br /> WASTE MANIFEST QALfolulll "K28 021824304 JJ K
<br /> 5, Generator's Name and Malling Address Generators Site Address (it different than mall" address)
<br /> At:IVWSAW
<br /> 1204 L AfIAW S I +
<br /> Gonerator's PW64)66,i
<br /> 6, Transporter 1 Company Name U.S. EPA ID Number
<br /> A1v1EfiIQAIN ilALLVY Y► KU'l L`- 0110 it+I ,
<br /> 7, Tronsporter 2 Company Name U,S, EPA ID Number
<br /> ` a C lit 'Yt:i i_ ,". Pi ,40AL f'Y WA611' S0IuU4I'I0NS , li+t e M NS000'i l (744
<br /> 8. Designated Facility Name and Sito AddreSs tU.S. EPA ID Number
<br /> i� 4- i;F' iNC;}'It�t t)1M }C;11Fr, i.i G . :" r ) r13<}8AARANCHO COMUOVA, CA &R;742
<br /> 1A3
<br /> § ItS.�;i 'tlitylT>": FR41C:lC fi,J. •
<br /> Facdif 's Phon6mrA 04,361,4&W
<br /> ga• 9b, U,S, DOT Description (maludng Proper $hipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12, Unit I3. Waste Codes
<br /> HM and Packing Group (ifpsrry)) fr+ No. Type Quantity Wt,Nol.
<br /> 1 R0 ( thil (:r`A3 1ft{6+AST"= F ( AI1AMAAJ F I Int fll'I9 N 0 9 'i N<311 1 fS(1)1 !iti y DOW CI973 33;
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<br /> 3.
<br /> 4,
<br /> 14, Special Handling Instructions and Additional Information
<br /> rrFk{SI= Ii.C:ti)• r1(9450 •05 GIVS, OIL Fet$S di 128
<br /> 15, GENERATORISIOFFERGk'S CERTIFICATION: I hereby declare that the contents of this consignment arc fully and accurately described above by the proper shipping name, arca are classified, packaged,
<br /> marked and lebeledlplacarded, and are in all respects in proper condition fortransport according to applicable intemationaland national govemmanisi regulations; If export shipment and I am the Primary
<br /> Exporter, I ccrtily that the contents of INS consignment tonfonm to the terms of the attached FPA Atknowlsdgment of Consent
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if ! am a large quantity generator) or (b) {dl am a small quantity generatoA is true.
<br /> Gana atoi'slDlferors 131, edfrypod Name Signatuy, t _ ':rr* monDa ar
<br /> 18. Inlematbnal Shipman i t to Portof L t
<br /> ❑ ImporttoU.S. ❑ Export from U,S, � enirytAxiL r
<br /> Transpdrtar signatum (fiat exports onlyy Date having U.S '
<br /> ~ .z il. Transp�rterA ?wledgmentofReceiptofMatedala
<br /> P�p PMrintedlry�e Famet r� 1 / .4819 Itur Month Day year
<br /> CL Vv T .ffs .' f ` ?` Vit! �r ;i :__ . • .: ��ff�''� - eel
<br /> Transpq erg Prinladfryped Name +rYr'��Signature P ' Month aDaf seat
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<br /> I 18. Discrepancy
<br /> 18a. Discrepancy Indication Space © Quantity ❑ Type ❑ kesfdue ❑ Partial Rejection ❑ Fdl Rejection
<br /> r Manifest Reference Number.
<br /> 18b. Altemale Facility (or Generator) U,S, EPA ID Number
<br /> Lim Faci)ity's Phone:
<br /> w 18c. Signature of PlJ to Facility (or Gonoratoi) Month Day Year
<br /> 19- Hazardous Waste Report Management Method Codes (loci, Codes for hazardous waste treatment, disposal, and recycling systems)
<br /> �Wy 1 , 2. 3. Notice : state of California requires
<br /> generator to photOCOPY and mail to
<br /> 20. Designated Facifity Owner or Operator, Certification of receipt of hazardous materials covered by the manifest except as tided in Item 18e DTSC With 30 daYss
<br /> PdntedfFyped Name Signature
<br /> POO Box 400
<br /> Sacra nento , CA 95812-0400 _
<br /> EPA Form 8700-22 (Revs 12-17) Previous editions are obsolete. vcNt:KA i CAR'S INITIAL COPY
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