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Kttjtl V tLJ <br />NOV 0 4 2013 <br />C�­ wi �4 t�e'. elite "ift� A CR x 44,T) Ca. <br />r t�q(� g 1, -0039 <br />Please print type. (Form dd'siginlefor use 1 6 r te�r?o Form Approved. OMB No. 2050 <br />AL <br />IT <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />Generator Number <br />2. Page 1 of <br />mergency Response Phone4.Manifest <br />rac in <br />Et <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address, 47 G nerator's Site Address (if different than mailing address) <br />J11 <br />Generators Phone: <br />6. Transporter 1 Company Name__ - ,J- C 7 U.S. EPA ID Number /_X <br />7 4, <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and Site Address U.S, EPA ID Number <br />9f r Vrj Oil, <br />Yk <br />104,Jx*8 67440 <br />Facility's Phone: <br />9a. <br />9b, U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />Wt.Nol. <br />1. ? Ali{. / A, A <br />d <br />0 <br />F_ <br />/'0 eel <br />Z <br />wel <br />Pt <br />3. <br />4. <br />14., Special Handling Instructions and Additional Information,., <br />t I= strwooriff to"t PM <br />15. GENERATOITSIOFFEROR'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 />Generator's/Offeroes Printed/Typed Name Signature— Month Day Year <br />_ J <br />16. International Shipments <br />0 ].Port to U.S. El Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW17. <br />U <br />Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 frintedfTyped Name Signature., 1 Month Day Year <br />0 <br />U) <br />Z <br />Transporter 2 Printedrryped Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />M Quantity El Type El Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />:3 <br />-<L <br />Facility's Ph... <br />0 <br />LL, <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />0 <br />05 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />Printed/Typed Name Signature Month Day Year <br />AL <br />IT <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />