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06 / 11 / 2021 1 : 39 PM FAX 2099488625 AMCE SAW 0002 / 0008
<br /> Please print or type. Fomi Approved, OMB No, 2050.0039
<br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3, Emergency Response Phone 4. Manifest Tracking Number pp
<br /> WASTE MANIFEST ,taf:Si �i '?)'r�3t: ;;:'• Y first)" 7.1i37+¢� f� ( � QF
<br /> INNORNMEN
<br /> 5, Generators Name and MailingAddreas Generator's Site Address (If different than mailing address) "'"
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<br /> 6. Transporter 1 Company Name U,$, EPA ID Number
<br /> Pil'IFRI(" Aiv VALLt'^.Y W AST17' 011. , ttdC). C;A,}�t3t}E1.�'i d 3Ile^
<br /> 7, Transporter 2 Company Rama 4 U,$, EPA ID Number
<br /> E�rI;F(li�Yt.l.k SPECIALl'4 VVAA 1. 2, SOLIJI'K7hi5, INC Iv1NSOrar1 'i -! QQ4
<br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number
<br /> kaEft4 fi<.IdC{ fs7 t I RI)OVA, LLCO
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<br /> FaOfliiy's Pnone� t ti-;3� 1 - tit*'rfif?
<br /> ya 9b. U.S. DQT Qescdplkm (including Proper Shipping Name, Hazard Class, ID Nufnbe6 10, Containers 11 . Total 12, Unit 18, Waste Godes
<br /> HM and Packing Group (if any)) No. Typo Quantity Wilvol,
<br /> N, 1 1,r', t ;Fd llrf-1,i , i+VA.`; 1'F �LR6l�trtAs'Tk 4' l .15 ( 1r';1�; , h! > ) • „;t I�f It , 1 01vi 53 DUlfJ ;iLi'3
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<br /> Id 14. Special Handling Instructions and Additional Information
<br /> tri;tit' II,I i�} ,1rF8:t7 lid {alfr4� . rail . I i''i1 #f # t'f3
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<br /> 16, GENERATOR'Sr4FFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately dessdbed above by the proper shipping name, and are classified, packaged,
<br /> marked and labeledtplacarded, and are In all respects in proper condition for transport according to appNarble international and nalfNdl governmental regulations, If export SHipment and I em the Primary
<br /> Exporter, l Wily that the conlents of this wnsi nment confomt to the terms of the attached EPAAcknewledgmentokGonsent. t
<br /> I cerlify thatihe waste minimization statement idonlified in 40 CFR 262.27(8) (WI am a large quantify generator) or ia) (NI am a small quantity generator) Is true.
<br /> Generator' efor's Prinisd/iyp'ed Name�-�- Signature Month pay Year
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<br /> 16. International Shipments V °* +
<br /> ❑ Import to U.S. Export from U,S, Port of entrylex'd:
<br /> Transporter signature (for exports only): Date leaving U,S.,
<br /> W 17. TranspoderAdmowledgmentofReoelptotmalenas
<br /> re TransporteJ Pte ypdd Name r Signature Y . ,y "' Mon D8y Year
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<br /> Try0po erg tRoltrypedName� OF f `Sfgnalur � ,. Month D Year
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<br /> 18. Discrepancy
<br /> 18a, Discrepancy Indication Space ❑ ••Duan6ly ❑ Type ❑ Residue IMP,
<br /> ❑ Partial Rejection ❑ Full Rejection
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<br /> M 'rifest Refe'rettce •Rumber.
<br /> 1Bb. Altempte Facility (or Generator) JV U.S. EPA ID Number
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<br /> LL Facility's Phone:
<br /> WINNOW
<br /> 18c, Signature ofAltarnate Facility (or Generator) Month Day Year
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<br /> 10, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, find cycling systema) Notice: State
<br /> 4. 2. $, r
<br /> generator to ph tocopyland mail to
<br /> DTSC With 30 days,,
<br /> 20. Designated Facility Owner or Operator. Cerdficatlon of receipt of hazardous materials covered by, the menifestexcept•as noted in Item 1
<br /> Pdntedffyped Name Signature . Bax 400
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<br /> Sacramento, +`A 95 C2ml?%5
<br /> EPA Farm 8700-22 (Rey, 1247) Previous edltions are obsolete. LI
<br /> GENERATOR'S INITIAL CiarY
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