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Please print or type. Form A roved. OMB No. 2050-0039 <br />A <br />P i¢ <br />ce Lir <br />Z <br />W <br />0 <br />ir <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 Generator ID Number <br />CAL000191987 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />800-326-1221 <br />4. Manifest Tracking Number <br />022013419JJK <br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />3 B'S AUTO & TRUCK PLAZA 14749 N THORTON RD <br />PO BOX 2695 LODI CA, 95242-0000 <br />LODI CA, 95241-0000 <br />Generator's Phone: 209-368-8100 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />AGRITEC INT DBA CLEANTECH ENVIRONMENTAL 1CAL000330453 <br />Transporter 2 Company Name U.S. EPA ID Number <br />HERITAGE TRANSPORT LLC 1 IND058484114 <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />HERITAGE ENVIRONMENTAL SERVICES LLC AZD081705402 284 E STOREY RD <br />COOLIDGE AZ, 85128 <br />Facility's Phone: 317-486-2778 I <br />ifs. 9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />iiki and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes <br />1. RQ,UN1993,WASTE FLAMMABLE LIQUIDS, N.O.S., 3,PGII,(GASOLINE, DIESEL), D001 — (D018 D001),ERG#128 1 DM 55 G <br />0018 <br /> X 331 <br />2 <br />3 <br />14. S ecial Handling Instructions and Additional Information <br />Document:: 14326366; Line 1: Profile #: 215258-1; DocuLine: 21439554; <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />FRANCISCO AVILA 1 FRANCISCO AVILA 1 01 1 14 1 2021 <br />--1 i- z — <br />16. International Shipments i Import to U.S Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. TransporterAcknowledgment of Receipt of Materials <br /> <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br /> <br />ALFREDO HERNANDEZ 1 ALFREDO HERNANDEZ 1 01 1 14 1 2021 <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />LUIS GUIZAR I LUIS GUIZAR <br />I 01 <br />1 22 1 2021 -*-• DESIGNATED FACILITY --o- 18. Discrepancy <br />Discrepancy Indication Space []Quantity OrYPe Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />H061 <br />2. 3. 4. <br />20. Designated Facility Owner or Operator: Certifica on of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />JESSICA GARCIA I JESSICA GARCIA 1 02 1 09 1 2021 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM