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E�TSC. 00594. 1310 <br /> Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.20560039 <br /> UNIFORM HAZARDOUS <br /> 1,Generator ID Number 2 Page 1 of 3.Emergaocy Response Phone 4.Man TNbar <br /> WASTE MANIFEST CAL000278332 1 909-721-2038 00 " " 797 17 0 JJ K <br /> S.Gemmws Name and Mar"Address Generators Site Address(if different than maSmg soonest) <br /> CIRCLE K STORESIMICHELLE WILSON CIRCLE K#2701205,16470 CAMBRIDGE <br /> 495 E RINCON,STE 150 LATHROP.CA 95330 <br /> CORONA,CA 92879 <br /> Generators Plain: 209-8584116 <br /> 6.Transporla 1 Company Name U S.EPA IO Number <br /> ENVIRONMENTAL LOGISTICS,INC CAR000172478 <br /> 7.Transporter 2 Company Name p, p U.S.EPA ID Number <br /> B.DaaffW�NI6 dM10ES. INC. US.EPA CNumaer <br /> CAD9$2444481 <br /> 180 W.MONTE AVE <br /> RIALTO.CA 92316 <br /> Faoliys wane: 909-421-2012 <br /> ga, gb.U.S.DOT Desoiption Imdudirg Pmpm Shipping Name,Hamot Class,l0 Number, 10.Corrur 11.Tool 12.Um 13.Waste Codes <br /> HM and Pacing Greup(d arty)) No. Type Qum" WUVoL <br /> 0 1. NON RCRA HAZRDOUS WASTE SOLID / DM /00 P 352 <br /> z 2. NON RCRA HAZARDOUS WASTE LIQUID DM G 134 <br /> So%d <br /> 4. bq <br /> 1/ <br /> I)AB 8 nNTW/FILTERS x08010509 IXSS WEAR APPROPRIATE PPE INV#49051 <br /> 98.2)WATER WIGAS 0031021 10 'x <br /> 5©304"CC41 ace jaw' PVC-- G—A S f�jc SS <br /> 15. OENERAMFrS/OFFEROR'S CER7IRCATION:I Maly dedare that the mntentsof this consignment are fury and acaretely descrW Shwa by to props shipping mine.and are classified,packaged, <br /> marked ant abeieNMecerried,and min a respects in Proper canthi rt for bareport accon"to applkaae Nlemadonaland national governmental agublOm,lesport shipment and I am to Pnmary <br /> EspwW,1 ow*clot to contents of this camgnment om(o m to the term of be attached EPAAdmDoledgrient of Consent. <br /> I cm*had the waste minim"Jon statement identified in 40 CFR 262.27(a)Id I am a large quantity generator)a(b)Ill am a strati quantity generator)Is M. <br /> GeneatohlOderors Rlmedrtyped Nemo Slgnaeae Month Day Year <br /> 06'+ wk - ` w 3 <br /> F 16.IntamatlaW Shipments ❑ImPp110U.S. ❑Eport fern U.S. Port of mb*& <br /> = Transporter slgatae(for epaa ont/1: Date kaNrg U.S.: <br /> W 17.TranSKMAdmo.Nsdgneaof Pa Otol Ma*WS <br /> Transft1 Pintedayped Name Signs" ManN Day/ Year <br /> Def 308 <br /> Z T 2 PMledfTyped Nam natu s Mph Day Yea <br /> i16.Discrepancy <br /> lea.Disompancy Indication Space ❑ Omy ❑Type ❑Residue ❑Pantie Rated. ❑Fu6 Rated. <br /> Manifest Refermre Nwftw <br /> 18b.Nlema a Facility(or Generator) U.S.EPA ID Number <br /> V <br /> W F.W,Phone: <br /> QW I SgmNne ofNamals FacrTdy(a Generator) Mph Day Year <br /> 2 <br /> 19.Namrdm Waste Report Management Method Cafes g e.,rooms for hamrdous wssa rose rtenl disposal,ars txyc ng syhrns) <br /> o I. oro 2 !g 3. N/ 4. <br /> 20 l5esignawd Fadety Owner or pperamor Cettfimtlon of receipt of hazardous matMals revered by the manias)encapt as noted m tarn 189 <br /> PrutWRyped Nana moo Day Yea <br /> 3197 8 <br /> EPA I=8700-22(Rev.305) Rrevmm editionsareabsolete. SIGNATED FACIL17YTO DESTINATION STATE(IF REQUIRED) <br /> 10319.1941 <br />