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Please print or type. Form Aooroved. 0MB No. 2050- <br />A <br />ce <br />R., <br />2 tu <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAC003203958 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />800-624-9136 <br />4. Manifest Tracking Number - <br />021395360JJK <br />Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />EXTENDED STAY AMERICA #8794 <br />2844W MARCH LANE <br />STOCKTON CA, 95219 <br />Generators Phone: 209-445-9315 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />PATRIOT ENVIRONMENTAL SERVICES I CAD053866794 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />HERITAGE-CRYSTAL CLEAN LLC CAL000282598 1620 E. BRUNDAGE LN <br />BAKERSFIELD CA, 93307 <br />Facility's Phone: 847-836-5670 I <br />ga. 9h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />KM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes <br />NON-RCRA HAZARDOUS WASTE SOLID (ABSORBENT AND DEBRIS WITH DIESEL) 7 1 DM 150 P <br />352 4 GENI NON-RCRA HAZARDOUS WASTE LIQUID (WATER WITH DIESEL) <br />7 6 DM 270 G <br />223 <br /> <br /> <br />- <br />14. Special Handling Instructions and Additional Information <br />Line 1: Line 2: <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, 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 (b) (if I am a small quantity generator) is true. <br />Generatoes/Offeror's Printed/Typed Name Signature Month Day Year <br />MIGUEL FIERROS I MIGUEL FIERROS I 11 I 12 I 2022 <br />-i 16. International Shipments <br />Import to U.S Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W u.i <br />1,2 <br />o_ u) <br />= < re 1- <br />17. Transporter Acknowledgment of Receipt of Materials <br />0 BRANDON <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />ECK I BRANDON ECK I 11 <br />I <br />12 I 2022 <br />Transporter 2 Printed/Typed Name Signature Moith Day Year <br />I I I I 4- DESIGNATED FACILITY -0. 18. Discrepancy <br />Discrepancy Indication Space Quantity IDTYPe El Residue Partial Rejection III 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 />H141 <br />2. <br />H141 <br />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 />TYRELL JENKINS I TYRELL JENKINS I 11 I 22 1 2022 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM