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Please print or tvoe Fenn AnnmvBd. OMB No. 205(1-0(139 EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. I KHlvaruK I rK wr 1 UNIFORM HAZARDOUS 1. Generator ID Number 2 Page 1 of 3 Emergency Response Phrre 4. Manifest Tracking Number WASTE MANIFEST 13525564 F L E 5. Generators Name and Mailing Address Gerwrators Site Address (it d.?terent than ^a! i 3CdJ-Ss) C T� k+,c Al�yry Tiuckini kw. 28302 Rd Lima us Carrat }iapnsq and R/. Hayward, CA 5 Tracy, CA X5377 Generator's Phone: 5tQLA,%Q.8BQ6 6. Transporter 1 Company Name US EPA A Numtp Atlas Emriwmentel Solutions CARDW2852" 7. Transporter 2 Company Name US EPA ID t6,to- B. Designated Facility Name and Site Address US EPA ID Nurrt- C�e�er HerbRn Buts VV 25017 t Lakem CAD9BOM278 Mum , CA 93"1 Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 OWa" 11 T01.21 12 Unit 13 'llas'e JJK No HM and Packing Group (if any)) Ouaruty Ylt:'lol 0 1 NOWRCRA HAZARDOUS V ASTE, SOLD, (DIESEL / 811 — - MPA TED SOL) / DT 2.a Z 2. W 0 3. 4. i I i 14. Special Handling Instructions and Additional Information a1meM ;fig 1)Cti18t3192 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 dassrfied, packaged. 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 111cert 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 mall quantity generator) is true. Valors/Offerofs ntedlT Name Signa r Montri Day( Year •P'r vtt J 16. Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: F— ? Transporter signature (for exports only): Date leaving U.S.: of UJI 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Phnted/Typed Name ar l Signature Month Day Ye Z Transporter 2 Tinted yped Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ U 1 Facility's Phone: In 18c. Signature of Alternate Facility (or Generator) Month Da Year Y H Q Z V5 19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) LAJ 1 2. 3. 4. 20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Signature Month Day Year PnntedTyped Name / ; ,' ✓i l.i:r., , t EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. I KHlvaruK I rK wr 1