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3725 N Tracy Blvd, Tracy, CA PR0521598 <br /> 01/20/2022 Program: HW <br /> PHOTO 4: <br /> Missin desi nated facility si ned copy(CORRECTED ON SITE) <br /> Pill— b� <br /> Fam Apppvad.OMB No.21150-0039 <br /> WASTE <br /> 015418334 NAtARREpOO� "raw,wa mn�nm„ z Pax+a a Errargaa.T ttegw�aa Pna. �. r.Aaglawaa -- 1 <br /> "Vn aN14aI„�Aaeea <br /> snru <br /> Momma.) a"'�M <br /> metal Ave ]iT'S N l lacy Blvd <br /> _ <br /> US EPAID Nu <br /> IlEl <br /> T � tlat$aMl(pntl <br /> Nana <br /> 0,5 EPAID Number <br /> a�Wnaed FaitlYNanlaad&Ia AdNau US.EPAIDNumba FLE <br /> 1v3e0 by 49 ov*rtm Waal lilt, <br /> CAU 0F8 404 019 <br /> F -h GA 91111111113 <br /> BOOS77.67?9 <br /> 9a BD.d,.6.DOT DeaYlpOpri(iMWing Pmpe,Sh,ppgq Name,l WaN C .ID Number, 10.Containers 11.Total 12.Unrt 13.Wasta Codas <br /> ilA d Paoklrlg Group(4 anYl) No. Type Q,---- WtNol. <br /> K 1 <br /> RU,UN 1993,lJaxte Fla nns”liquid,N.O.S,3,PCsItr <br /> (reac)IRO Ono 1) <br /> w 2 <br /> 3 <br /> 4 <br /> 14,Special Handling InsWctions aM Addiaorel Information <br /> 1'Jnal►at•1=. EkG l5z, <br /> !'latdr 9b! 115757 <br /> f rTte-l(!p„c�Callad J/N itiwurs 510-511-�l <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,old are classified,packaged, <br /> marked and labeledlplacarded,and are In all respects In proper condition for transport according to applicable Intemalionaland national governmental regulations.d export shipment and I am the Primary <br /> Exporter,I certify that the contents 0 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 generate,)or(b)(if I am a small quantity generator)Is true, <br /> Signature Month Day Year <br /> Generatofslt7Rerors Pdntedrtyped Name <br /> 1 <br /> 16.Intemation hip m n ❑Expos from U.S. Pott ofenhylexit. <br /> Y Import to U.S. <br /> r ? Transporter signature(for exports only): Date leaving U S: <br /> K17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> �Transporter 1 PdSignature Mand, Day Year <br /> ntedlTypetl Name �(a' <br /> Z Transporter 2 Pdnted[Typed Name Signature '-J) Mond, Day Year <br /> Q <br /> K <br /> F <br /> j18.Discrepancy <br /> 18a.Discrepancy Indication Space F]Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> IManifest Reference Number: <br /> US.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> tai FaciliVS Phone: Month Day ,a- <br /> LO <br /> ear <br /> w 18c.Signature ofAltemate Facility(or Generator) <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems 4 <br /> 2 3. <br /> rudest ia� <br /> - - 20.Designated Facility Owner or Operator:Cedification of receipt of hazardous materials covered by the mS gnaturecepl as stied in Item i8a Month Day 'feel Illit <br /> PrintedRyped Name <br /> EPA Form 8700-22(Rev.12-17)Previous editions are obsolete. <br /> GENERATOR 51NITIAI COPY <br /> VICKY VANG-LEE, REHS Page 4 of 5 <br />