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Please printor - <br /> type.(Form designed for use on elite(12-pitch ✓ 1:� �a <br /> UNIFORM HAZARDOUS 1.Generator lD Number )typewrite[) EES-A4 �r <br /> WASTE MANIFEST 2.Page i of 3.Emergency p°Res nse Phone Form Approved.OMB No.2050-0039 <br /> 5.Generator's Name and Mailing Address r 4.Manifest Tracking Number 1 <br /> L C-lre'r .7i-GOO-7[1-9300 11044 ' X159 JJK <br /> �a4 P�y-y)GC Generator's Stte Address(if different man mailing address) r „ <br /> SToGkTQ- Ct y'f l0r <br /> Gendmtoes Phone: _ RECEIVED <br /> 6.Transporter 1 Company Name26-j X <br /> s:VVERCMIHE'N E'NVIRONMENTr'tScOyVIC1:;:� <br /> 7.Transporter 2 Company Name 1p U.S.E Al0" umber <br /> ti;Araf3e2a132H�` <br /> Number ) <br /> e.Designated Facility Name and Site Address SAN JOAOUIN COUNTY U.S.EPA ID <br /> t-V- GREEN OIL, INC OFFICE OFEMERGENC <br /> 5880 NUSc U.S.EPA ID Number <br /> SMITH AVE <br /> NEG"DARK CA 84560 <br /> FaciliI Phone: 310-7964400 CA?7;a30R 7.18 <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(If any)) 10.Containers 11.Total 12.Unit <br /> y 1. No. Type Quantity Wt.Nol. 13.Waste Code, <br /> a Nora-Rc�a rlazk,Fr(I_�c�l�sASTLr LIrgS i <br /> Z 2 <br /> cD <br /> i <br /> 3, <br /> 4. i <br /> i <br /> 14.Special Handling Inid [Bons and Additional Information <br /> PROFILE ;# __ __ _ _ __..--.._-._. v'Jt)Ii E ,# V 7d/�'0 <br /> LOT+ RG#171 WEAR PROTECTIVE CLOTHING ;ALES ORDER <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 Iabeledlplacarded,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 /> Expands,I rartify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I codify 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 /> Gerard to sl fferofs/.PP ted/rr d Name Signature Monm Day Year i <br /> // s-^C <br /> Vic++/� � '�-� � 6 <br /> J 16.Inter ational Shipments <br /> i- Import to U.S. ❑apod from U.S. P <br /> 11 Import of entry/exit _ <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TmnsporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printem Typed Name Signature Month Day Year <br /> O <br /> QTranspod rI rinted/Typed Name Signature Month Day Year <br /> K <br /> F <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ty ❑Full Re <br /> ❑ QuanB El Type ❑Residue ❑Partial Rejection lection I <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Fadlity's Phone: <br /> ud 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Re rt Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 7. I 2. 3. 4. <br /> 1 20.Designated Facility Owner or Operator:Certification of receipt of haze ous materials covered by the manifest except 9s road in.Item 18e <br /> Pnntedrryped NemeJ Si nature Month Day year <br /> _ 9 <br /> EPA Form 5700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> �- / 7- 0 R� <br />