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please print or type.(Form designed for use on elb(12pitch)typewriter.) Form Approved.OMB No.2050-OG39 <br /> UNIFORM HAZARDOUS 1.Genamtor ID Number 2.Page 1 of 3.Emergency Response Prone t Menff"t Tracking Number <br /> WASTE MANIFEST �.�LoOG_-b37:2 1 a,,a--_1 '-118 1001870797 JJ K <br /> 5.Genemors Name and Missing Address Generators Site Address(H different than matfing address) <br /> CIRCLE K ST0RE31tA:CHE1JLE 504 00N CIRCLE K#2701205,13470 CAh43RIDGE <br /> 495 E RINCON,STE 15C LATHROP CA 95330 <br /> CORONA_ CA P287e <br /> (ienerato'sPh": '_09-859-41!6 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ENVIRONNIENTAL LOGISTICS, INC CAR000172478 <br /> 1.Trummoner 2 Comp"Name U.S.EPA ID Number <br /> 6 Li ��L1N "= ViCES INC U.S.EPA ID Number <br /> 180 W.fAONTE AVE CorD982444461, <br /> RIALTO CA 92316 <br /> Fabilys Phone: 909-421-2012 <br /> as 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10,Containers 11.Total 12.Unit 12 Waste Codes <br /> HM and Padding Group(Harry)) No. ryas Quantity mjw. <br /> C 1. NON RCRA HAZRSOUS WASTE SOLID / l /OD PL3522. NON RCRA HAZARDOUS WASTE LIQUID DIV G <br /> 7 �/ / SO <br /> 3. �'O/V ^ C 77i�2/ti'CJQG[,$ ! S/G_ <br /> 4. <br /> 14.5nallriformaton <br /> 1211)AdBr�,OrMr SENTE TERS#03010509 I XSS WEAR APPROPRIATE PPE 11,A449051 <br /> 9621Vv'A.TER W,'GAS#031021101 /xSSGgf <br /> 15. GENERATOR WOFFEROR'S CERTIFICATION: I hereby doom that the contemn of this consgnmernt are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are In all respects in proper condition for transport according to applicable International and national govemmental regulations.H export shipment and I am the Primary <br /> Exporter,I codify that the contents of this consignment conform to the terms of the attached EPAAcknoMedgmam of cwwem. <br /> I ced6y,that the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or Ib)If I am a smell quantity generator)is true. <br /> Generetors/Ofe(oP9 PrintedRyped Name Signature Monro Day Year <br /> ab0,+- �kr� w �� 3 / <br /> r 16.Int"onal Shipments <br /> Transporter signature(for expmts a*): Import to U.S. ❑Expert from U.S. Data <br /> extryng Udit <br /> U.S. <br /> W 17.transporter Acknowledgment of Receipt or Matinees <br /> fy, Trans 1 Printed//ryped Name Signature Mor?M Day Year <br /> Trans 2 Pnntednyped Name hgnature Month Day Year <br /> of <br /> ti <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Space 11 ��, ❑Type ❑Residue ❑PartialRepceon EJFuli Rejection <br /> ManHnt Reference Number <br /> 180.Ahemate Fool for Generator) U.S.EPA ID Number <br /> ad <br /> V <br /> FeGNys Phew: <br /> 1&.Signature of Alternate Facuky for Gra eretw) Monet Day Year <br /> 2 <br /> 5519.Hazardous Waste Report Management Method Codes(i.e.,codes for nazarows wasw pastrami,d <br /> yispasel,and regGing systems) <br /> 0/0 2 f 3 4 <br /> 2G. eugnated Fadity Owner orrator.-erGrvator.of receipt of hazardous,materials covered by the manifest except as nosed in ken Ise <br /> fimN'iypad Name ti 3rgnalure Monty Dav Year <br /> tA�l 3 a7 Pe <br /> _- - Fes°-05) revious edurons a re obscle!e. P-61GNATED FAC!L!!7TD DESTINATION STATE (!t= REQU!RED) _ <br />