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IIII IIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Form A roved.OMB No.2050-0039 <br /> PP <br /> Please print or type. 4.Manifest Tracking Number <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 6 F L E <br /> UNIFORM HAZARDOUS 1 (877) 577--`x,69 <br /> WASTE MANIFEST t ALr000,39,°,335 <br /> Generator's Site Address(if different than mailing address) <br /> 5.Generator's Name and Mailing Address O' Reilly Auto Farts#.3810 <br /> O' Reilly Auto Farts <br /> 1551 WEST MAIN STREET <br /> 178747257 1551 WEST MAIN STREET RIPON, DA 95,366 <br /> Generator's Phone: RIPON, CA 95366 U.S.EPA ID Number <br /> 6.Transporter 1 Company Name MNS0001 109`4 <br /> Clean Earth Specialty Waste Solations u.s.EPA IDNumber <br /> 7.Transporter 2 Company Name t <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address i= s e n tar y , <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> NVD98089S;s38 <br /> 7755752760 I <br /> Facility's Phone: <br /> 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Quantity Wt.Nol. <br /> and Packing Group(if any)) N0' Type <br /> HM CF 00003 Fr X14 �D!001 <br /> waste ammo a 4uz s, n. o. s. .. e.. .� <br /> o <br /> (Acetone, Methanol), 3, PG 11, ER t <br /> I <br /> R 4 <br /> 1 C X0005 R 141 DO02 <br /> V , as a orr^osave aur , bask, „ <br /> 0 inorganic, n. o. s. (Sadism Hydroxide, <br /> Potassium Hydroxide) , 8, PG II, ERG#154 1 <br /> 3. ' <br /> t <br /> i <br /> 4. <br /> 3 <br /> 14.Special Handling Instructions and Additional Information 0( a m m a b l e I+l C}U 1 d 5) i'• 16 'g(8a S 1 C L l i�it l d 5 (,O r'r O s 1 V e) <br /> i <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: Thereby 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 terms 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( (if I am mall quanti generator)is true. Month Day Year <br /> � <br /> Gener r fferor's Printed)typed aJme OF Si ure '04 01 1021 <br /> ►v V <br /> 16 n national Shipments ❑Export fr m U.S. ort of ent <br /> t— <br /> ry d: <br /> ❑Import to U.S. Da avi <br /> Z Transporter signature(for exports only): <br /> W17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> Transporter 1 Pr nted Typed Name Sig ture <br /> 04 01 021 <br /> a nthony Mack Signature Month Day Year <br /> Z Transporter 2 PrintedlTyped Name <br /> F- <br /> 18.Discrepancy <br /> ❑ Residue <br /> 18a.Discrepancy Indication Space Quantity Type ❑ ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 181b.Alternate Facility(or Generator) <br /> J_ <br /> Facility's Phone: Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> I� Q <br /> Z <br /> N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disp3sal,and recycling systems) 4 <br /> C 1. 14' 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except a_ d in Item 18a Month Day lga� <br />,r <br /> Printed/Typed Name Signatur <br /> EPA Form 8700-22(Rev.12 17) Previous editions are obsolete. <br /> DESIGN ED LITY TO EPA's e-MANIFEST SYSTEM <br /> c J M 1°'Dt�401.;_?1 :�st�t��+t111:�t <br /> A700-22 1 c v 3 CAL40000003 54109788' 042036526 <br />