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• Form Approved.OMB No.2050-0039 <br /> .Please print or type.(Form designed for use on elite(12-pits pewriler.) <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Mrac8in9 Nu 4 <br /> ber <br /> UNIFORM HAZARDOUS 0 0 6 5$4 512 JJ K <br /> WASTE MANIFEST -' r <br /> 5.Generators Name and Mailing Morass <br /> ,y Generator lte ress( eren than mailing address) <br /> Oak Grove Regional Park 4520 W. 8 KI Rd. <br /> 11793 N. Mickey Grove Rd. Lodi, CA. 95240 Stockton, CA. 95209 <br /> Generators Phone: - -� U.S.EPA ID Number <br /> 6.T. perter,1 Company Neme 944 -5�16 <br /> RAMOS EtdVLR00l it U.S.EPAID um an <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address <br /> RAMOS ENVIRU*ENTAL SERVICES <br /> 1515 SOUTH RIVER ROAD, WEST SACP.AMENfO; CA 95691 <br /> Facility's Phone: <br /> 91 <br /> (including Proper Shi Name,Hazard Class,ID Number, 1D.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. 9b.U.S.DOT Description(' 9PP n9 No. Type Quantity W1NOI. <br /> HM and Packing Group(d any)) <br /> 1. 90N-RCRA HAZARDOUS WASI' LIQUID 2 t <br /> o (OILY WATER) <br /> a <br /> Z 2. <br /> w <br /> co <br /> 3. <br /> 4. <br /> 14.Special Handling lnsfiuclions and Additional lnforma8on 1.-1i:,1; 1.i J. <br /> HANDLERS TO 8E TRAINED AND USE PPE. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and aomretely described above by the proper shipping name,and are ciassfied,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemafional and national governmental regulagons.If export shipment and am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPAAcknoWedgment of Consent. <br /> cedify 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 tme. Monts Day Year <br /> Signature - <br /> GeneratorslO9 acre Printed/Typed Name j <br /> 16.Intemational ShOtntsImport to U.S. ❑Fxpert from U.S. Port of entrylexil: <br /> i- Date leaving U.S.: <br /> Tanspoder signature(for exports only): <br /> 17.TrensporterAcknow'ledgment of Receipt of Materials Month Day Year <br /> w - Signature <br /> Transporter 1 Pnnteaf IYPed Name 1 /, �J <br /> O I <br /> EDiscrepancy <br /> - Month Dayryped NameSignature <br /> don Space ❑ Quantity <br /> ❑Type ❑Residue ❑Pallial Rejection Full Rejection <br /> Man9est Reference N,mher. <br /> U.S.EPA ID Number <br /> 181b.Alternate Facility(or Generator) <br /> J <br /> 4 Month Day Year <br /> LL Facillly's Phone: <br /> ILL! 18c.Signature of Altemale Facility(or Generator) <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Medved Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> w 1 2. 3. <br /> o ' <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> 1 Signature <br /> PrintedRyped Name <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />