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a .. <br /> Pleas&prad or type.(Ecom designed for use on efle(12-1 typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.'3"ansar IDNrAnber 2.Pie1of 3.Emmgency,Response Phone 4.Manliest Tacking Nrmrber <br /> WASTE MANIFEST C o :� n s 9 'I WG 424-9300 G� � 0"_ 11566 JJK <br /> S.Genaranrs Name and Mating Address Geneames SheAddress Cddiaeremtlen mi address) <br /> QlJr.K*TRUCK REPAIR <br /> 100 E MINER AVE <br /> 8T0CKT0f4 CA u5205 <br /> Geraalots Phone: n <br /> S.Tmnsporntr l Company Name U.S.EPA ID Numbaz <br /> FRFPvX)1 W EaNMRONME-.NTAL SERVICES NG C: A P 0 0 0, 1 'i 7 t) 1 7 <br /> T TraoporprY CompayName - U.S.EPA ID Number <br /> 8.DestgnaEad Fadly Norrie andSaa'Addan U.S.EPA ID Numi <br /> isiCOiXi.N ' <br /> ::WCHEVRON Yva <br /> DiX(N: Z�A S15620 <br /> Fed ftye Rommi: 711717 „�:�_^ .,a C %�. +� 6 0 2 <br /> ga 9b.U.S.DOTDaswoon foducing Proper Wppirg N�.Knod Cim.ID Numbs; 10.ConFavhers 11.Tiew a Una 13.Wale Codas <br /> NM and Pecking GmW(if any)) No. r Type Ouamay, Wi <br /> ¢ WON-RCRA IiA7AfRDCXJ'S d'A3?'E._ii(OILY'WATER) �3 t <br /> 1 t (T <br /> a 2. <br /> ty <br /> t•! <br /> 3. <br /> i <br /> 4. ' <br /> � I <br /> i f <br /> 14.Speda Hai lnstructuas and Additional lMomation .); O)iy YlPater ERG#i 7'1 _ <br /> DEPARTMENT <br /> k{,1"NIJA.F�S 1'U EiII 40NILrirtAYMtiG.01,US!: PNET. <br /> 15. GENERATORS/OFFEROR'$CERTIFICATION:I hereby declare stet are contents ofttis consignment arefWy andaccmi desolbed above by the proper shipping name,and are classified,packaged, <br /> marked and laheladtplaaarded'aid are in an aspects in proper condition for bansportamonfing to applicable ftnartionaland national govertvneutal mi Itexpcdshipment and I am the Primary <br /> Exporter,I cermy that the contents of;tis coragnmentcanfenn to the tears of me attaclred EPAAdmoaledgmm:t of Consent. ' <br /> 1 ceNty that the wast:milmmogtionstminnent identified in 40 CFR 26227(a)(d I am a large quantity generadr)or(b)(al am a anal quantity geneata)is nue. <br /> Geneatdsr(Meemes Prartedffyi ed Name 3gnume Mono Day Year <br /> J 15.International Shhhmmts <br /> F ❑Import to U.S. ❑Expert from U.S. Foo ofenbyledh <br /> i2— Tareponersignature(for exports only): Date leaving U.S.: <br /> W 17.Tms oomAdmcWedgrnmd ofReceipt of Mateiels <br /> .1}arsponar1 nmd(fyPmy Name SlgnaWre Month Dai Year <br /> 17 <br /> Tansponer 2 PrurmfTyped Name "nowe Month Day leer <br /> K <br /> r <br /> 19.Discrepancy <br /> 13a.Discrepancy Indication Space D Quantity DTYP, ❑Residue ❑Partial Rejection ❑FWI Rejection <br /> Manfesi Reference Number. <br /> teb.Allemata Facility(or Geneator) U.S.EPA ID lumber <br /> J <br /> U <br /> corn- <br /> Facility's Phone: <br /> W- ito.S'gnatnre ofAltemate Feaity(of Gerasti Morm Day Year <br /> a <br /> z <br /> S2 19,Hazardaus Wash,Repan Marmgenant Meted Codes Ira,codas for hazardous waste meanest disposal,and recycling systems) <br /> i. . 2 3 4, <br /> 20 Designated Fadity0w mOpemtw'CeMealmofreceiplofhazaNwsmMaMscoveradbythemmffestexcepteendedhbmlea <br /> PmNd(fYped Name Signi ) IN, DAY Year <br /> EPA Form 8700�22(Rev.3-a5) Prewos TRANSPORTERS COPY <br />