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3725 N Tracy Blvd, Tracy, CA PR0521598 <br /> 01/20/2022 Program: HW <br /> PHOTO 5: <br /> Missing designated facility signed copy (CORRECTED ON SITE) <br /> ( HealI or ,(Paan ,UNIFOM Nfor We an e 12 Form Approved.OMB No.2050-0039 <br /> �ROOUB <br /> ' Nfgg'TE e1MII1. lib FFSTU udIs 2.Papp a,Fmergacy RerPonae Pnorb 4.M.Kn Tracklnq Number <br /> r, INamaandrAarr,n N 000361591) 1 5105e1-212f <br /> 1� 9Addma, , r man1 0117:::.a>v���'..� FLE <br /> - 3725NTm y131 <br /> �enerabra Pnoim. ;,•�h;02� Til CA 05104 <br /> 3 cansppri� <br /> y <br /> 1'19 iIHWTp1/1i-Mal Su41Uo(K <br /> U.S.EPA IO Number <br /> .sranaporta12 CO^tPanY Name 'r'V GS NJ 14.ar-,.,V+) <br /> Ui�-il`aPrU 1C^ U.S.EPA ID Number <br /> B.Daeignaed.Fadlily,Name and Srle Addmsa F�17' <br /> '�f._. �' nnaU.S.EPA ID Number <br /> 4r Att p,tN Fe:N}D-; '�xflNh d Beall <br /> Fapli sPhone: 00'� 9'�4�./'j <br /> 9a. 9b.U.S.DOTDespip6on(indudirg Proper Shipping Name,Hazard Class,ID Number, 10.Containers e <br /> HM and Packing Group(deny)) 11.Total 12.Unit <br /> No. Type Quantity M.N.I. <br /> Waste Codes <br /> o !iN f9HJ,vlaslr naernrrable Lquld,N.O.S..J.PG 10(G x; <br /> v�rMe.f <br /> w 2. <br /> A" " Non RCRA Hilumdous Vftdt Sow(Oiy Dill <br /> a <br /> I <br /> 4. <br /> f ,14.S 9 ; <br /> !1 1. ,x, F agdlin Instruclipps afdAQpppha,Information <br /> If "RGENCY CONTACT EFF RHODES <br /> 15, GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare 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 tens of the attached EPA Acknowledgment 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 time, <br /> Generator's ORero's Printed yped Name Signature Month Day Year <br /> 16.international Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entrylexiC <br /> I — <br /> Transporter Signature for exports only): Date leavin U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Matenes <br /> Transporter 1 Priatecirryped Name Signature Month Day ear <br /> d <br /> a? a' Transporter 2 Pdntecirryped Name Signature Month Day year <br /> H <br /> 18.Discrepancy <br /> j Ise,Discrepancy Indication Space ❑Quantity ❑Type ❑Residue Rejection <br /> 7eclion <br /> I Partial Re ❑Full Re' <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Familitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day year <br /> 6 <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. a• 4. <br /> Designated Facility Owner or Operator:Certification of recelpt of hazardous materials covered by the mall except as noted in Item i8a <br /> I Printed/Typed Name Signature Month Day Yoar <br /> EPA Form 8700.22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 77 i! <br /> VICKY VANG-LEE, REHS Page 5 of 5 <br />