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Pleasepdntor pe.(Formdesig edfor(pyeeoelilrf(12•pitch)typewriter)t` f .•'`. It4 <br /> 1.GenwillorlD Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAR�OQS 1 2.PageloT 3.Emergency esponse.Pfane 4.Manifest Tracking Number <br /> WASTE MANIFEST �{�,0:(j(j ,� C�'.r3 g (8u0) a, - <br /> 0140519015. JJ K Generators Name and Morning Address <br /> COUNTRY MARKET AGE DM SARI EKTERPRISE Generators Site Address(if different marrmailing address) <br /> 1783 hit'CHARTER WAY <br /> STOCKTON CA 96206 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name - <br /> - U.S.EPA ID Number <br /> AStIB.Y,E(P)!IBONf�E[t€Ilc4 SELY.NvS �' G A 4�o Z 8 a 1 Z Q 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> APR ©6 216 <br /> 6.Designated Facility Name andySBe Address <br /> DEMEN d�/t�€R�p�� U.S.EPA ID Number <br /> 2000!$.ALA EDA STREET <br /> COMPTON CA 90222 <br /> FadBys Phone: Q 1 0=7-7JL`ATO80013852 <br /> ga, 9b.U.S.DOT Descup5on f®dudig Proper Shipping Name,Hazard Class,ID Number, fOContainers <br /> y6 <br /> NM and Packing Group(dany)) . 11.Tolal 12. n 13,Waste Codes <br /> No. a Quantity <br /> 1. <br /> F NONAC RA HAZARDOUS WASTE,LIQUID(OILY WATER) � � 2 I <br /> MC - - --{ - <br /> 3, <br /> 4. <br /> LU <br /> CD <br /> v) <br /> 14.Special Handling lnsWdions and Additional Information -f r. � +r.. <br /> EMERGENCY CONTACT�CHEKTREC 1.800424-9kO NALRGxf 1;'R ° PROFILE 901 : 319165 OILY WATER <br /> PON A11020408 " APPROPRIATE PERSONAL PROTECIrvi <br /> air/ � - <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of mis consynmentaretuly and accureley descdbed above byfhe proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects In proper condition for banspod acmMing to applicable International and national governmental reguWLrons.if export shipment and l am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknossledgmentof ComanL <br /> i Wilily that the waste mfnimizatbn statement identified In 40 CFR 262,27(a)(it l am a large quantitygensrater)orIll)Ill l ams mall quantity generator)Is We. <br /> GeneralorslOR Des PdntedRyped Name Signature Month Day Year <br /> X7 7: ,i a.V <br /> 16.International Shipments -- <br /> Z ❑Import to U.S. ❑Export from U.S. Pod of enbylexit:_ <br /> Transporter signature(forexpods only): <br /> 17 Tans Date leafing U.S.: ' <br /> r11 twderAdmow7edgmentNRecelp(ol Maledals <br /> C Trans 1 Pdnled?PANSignature Month Day Year <br /> -- " <br /> Transpoder2PdnledAyped Name 03 a vv <br /> nature Month Day Year <br /> H <br /> 18.Discrepancy - <br /> 188.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Re action <br /> j ❑Full Rejection <br /> IBb.Alternate Facility(or Generaloq Manifest Reference Number: <br /> _ U.S.EPA ID Number <br /> CJ . <br /> LQ Faciliys Phone: <br /> N18C.Signature ofAffemate Facility(orGenerator) Monty Day Year <br /> z <br /> 19.Hazardous Waste Report hlsnagement Method Codes(i e.,codes for hazardous waste treatment,dispose].and i <br /> Q I 2 , po recycling systems) <br /> 3, 4, <br /> 20.Designated Facility0rmer a 0peralor.Cedlfiwtion of receipt of hazardous materials covered by the manNest except as noted in Item 18a <br /> Printed/Typed Name CC Signature Month Day Year <br /> :PA Form 8700-22(Rev. -05) Pr� ditionsareobsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />