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Please print or type.(Fano designed forum on elite 12-pitch typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emagensry Response Plrone 4.Manifest TracI Number <br /> WASTE MANIFEST CAL00 2 - 0 0 42 <br /> 5882 JJ K <br /> S.Ganeretars Name and Maling Address Geireralot s Site Address(it dererenl then meting address) <br /> CIRCLE K-STORESIMICHELLE WILSON <br /> 495 E RINCON,STE 150 CIRCLE 16470 CAMBRIDGE <br /> CORONA.CA 92879 LATHROP,P,CA CA 95$3533 0 <br /> Generators phone: 815, <br /> 6.Transporter 1 Company me U.S.EPA ID Numbs <br /> ENVIRONMENTAL LOGISTICS, INC1 <br /> 7.Transporter 2 Company Noma U.S.EPA ID Number <br /> I <br /> 8.Designated Facility Now ant Site Address US,EPA ID Number <br /> FILTER RECYCLING SERVICES,INC. <br /> 180 W.MONTE AVE rarwa?deaeal <br /> 'RIALTO,CA 92316 <br /> Facill laillow: 800-698-4377 <br /> ga. go.U.S.DOTOesrdpdon"using Propar Shipping Nam,Hazard Class,ID Number, 10.Coll 11.Total 12.Unit 13.WaeN Codes <br /> HM and padding Group Of any)) No. Typo Guanloy WWW. <br /> o 1. NON RCRA HAZARDOUS WASTE SOLID I fndA J o P 3352 <br /> Z 2. NON RCRA HAZARDOUS WASTE LIQUID '� DM 50 G 134 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions aid Additional Information <br /> 981)FUEL FILTERS#03102111 )$S-C- WEAR APPROPRIATE PPE WHEN HANDLING. ItIAM 58815-N <br /> 982)WATER WIGAS#03102110 V ST'-' , <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contints of tfds consgnmeM are hilly and accurately described above by the proper shipphg mama,and are classified,packaged, <br /> marked and labNedlplecarded,and ere In all hapecls In proper condition for transport according to applicable international and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I cannily that the contents of this consignment conform to the terms W the attached EPAAchnowdedgment of Consent. <br /> I ca8ry thal the waste mi unizagan statement Identified In 4 CFR 26227(a)(it I am a large quantity generator)a(b)ff I am a small mmu nerator) <br /> Ge rs Pdn Name SgnatuWS MaJm Y�a{er <br /> ,.x 16,International Shipments r /T�� 6/7 V <br /> F ❑hnpMbU.S. ❑Export two U.S. Pod of emrylexit: <br /> 6'3 <br /> Transporter signature ffor exports only): Dale leaving U.S.: <br /> W 17.TresporterAcknovledgmerd dR of MaledWs <br /> T{msponer 1 PdnleMype Sngral A1oph Qty Year <br /> a L ELS. ii/CLi <br /> RTransporter Pdnl yped Name Times Month Day Y <br /> H <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Space ❑ Quantity 1 Type ❑Residue <br /> 1g ❑Partial Rejed'pn ❑Full Reiedipn <br /> c j0W'?JrN ItC,411b,64 id- dure.rP0, "S i Wl <br /> Marete6l Reference Number: <br /> tells.MemaM Fadlry(or General U.S.EPA ID Number <br /> U <br /> LL Facility's Plane: <br /> W lac.Signature of Alternate Facility(w Generate) Month Day Year <br /> Q <br /> 2 <br /> H <br /> is Hazardous Waste Report Management Memod Codes(i.e.,codes for hazardous waste treatment,disposal,and racychng syalmos) <br /> our� I 2 G. 4. <br /> 20.Desgnated FadBy 0wr a a Opter:Ceff"Gon of receipt of hazardous matedals covered by the manifest except as noted in Item 180 <br /> Pnnwdffyped Name Signature Moro Day Year <br /> EPA Form 8700-22(Raw3- ) Pre 'ouseditions are obsolete. DE NATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> I <br /> I <br /> l <br />