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Please print or type. Form Aotjroved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />I. Generator ID Number <br />CAC0031 65805 <br />2. Page 1 of <br />11e <br />3. Emergency Response Phone <br />1-866-547-2857 <br />4. Manifest Tracking Number <br />0 1 6 9 9 6 3 9 4 FLE <br />5. i edlor's Name Mailing Address f <br />0#13 or:de Lane *5105 <br />Ge at r's Site Address (if different than mailing address) <br />30a -121 400003 ... NM <br />C <br />Stockton, CA 95212 Lodi, CA 95242 <br />Generator's Phone: <br />6.Arsoprter J Company Name U I Environme I Services LLC .S. EPA ID Number <br />1 CA1000421863 <br />7. Irausoortet 2 CCIMIDalIV Name. Atlas EnvirOnMenb,1 Solutions uako burnbek 0295220 <br />I <br />8' Eitiltiffili nVidution s , Inc. U.S. EPA ID Number <br />31915 industrial Lane AZR000520478 Parker South , AZ 85344 <br />Facility's Phone: I <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number, 10. Containers 11. Total 12, Unit <br />HM and Packing Group (if any)) No. Type Quantity Wt./Vol. 13. Waste Codes <br />cc <br />0 ..,1--- <br />a <br />1.Non-RCRA Hazardous Waste, Sold (ABSORBENT, DESEL) V T terOt P <br /> 352 , <br />i <br />z 1.1.i <br />0 <br />2. <br />I <br />! <br />3. i <br />i <br />4. <br />Document: D330959 Spt.10-1§ttatptsdditional Information <br />1 ) <br />C>.( Bill to: Atla <br />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, aril 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 tam a large quantity generator) or (b) (if I am a smty generator) is true <br />Gen eror's ' ted/Zd Nam . sda/AJot <br />Signature Moptly Day Year <br />'-51- e--- / <br />i <br />F-- <br />International Shipments LII Import to U.S. LII Export from U.S Port of entry/exit: <br />F.. Transporter signature (for exports only): Date leaving U.S.: <br />rx tu Transporter Acknowledgment of Receipt of Materials TRANSPORTI <br />rind ame A Signature _ Mont Day, Year Transp ter 1 Pttrype <br />Z-(240-ye.- I I I i'r 2 z <br />Tr <br /> <br />porter 2 Printed/Typed Name Month Day , <br />I Sig <br />ure, <br />1 3 121 <br />Year <br />IV. I -t- DESIGNATED FACILITY ----'• 18:Discrepancy <br />Discrepancy Indication Space Quantity LIII Type Residue LIII 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) <br />, <br />Month Day Year <br />I I <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4 1. 7:-114' 2. 3. 4. <br />• Designated F . ly Owner or Operator: Certification of receipt of hazardous materials covered by the manif t e cent as ncted in Item 18 <br />Printed/TK:11_ a..9...„‘ z----X <br />I TA <br />. Ninth Day Year <br />--sd 131 laa <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are o olete. DESIG)AT& FACILITY TO EPA's e-MANIFEST SYSTEM