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State aT alifornio—Environmental Protection Agency /-73 g <br /> ,Fiiym✓i{psbvpl OMB No.2050-0039(Expires 9-30-991 See Instructions On back Of�e 6. Department of Toxic 50bslances Control a <br /> Places.p.1 or type. Fonn designed for use on elite112-pik' Oiter. Sacramento,California <br /> UNIFORM HAZARDOUS �C'A <br /> Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areai - <br /> is not required by Federal law. <br /> WASTE MANIFEST ) CI 01 N S 2 S 5 09 0 1 of 1 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 10220 S,W. GREEtMBURG ROAD ;1470 22362772 <br /> o PORTLAND, OR 97223 B. State Generator's ID <br /> ul C6 4. Generator's Phone(503 ) 977-7713 <br /> tV 5: Transporter 1 Company Name 6. US EPA ID Norther C. state Transporter's ID[Reserved.] <br /> L <br /> W <br /> 6 BELSMIRE ENVIRdNMENTAL SVCS. all D. Transporters phone 949-450-1010 <br /> O. <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. Stale Transporter's ID[Reserved.] <br /> J- <br /> �Q F.Transporter's Phone <br /> �U 9. gesigttp(e�f_gcililyJl'ploe.arr�$ite Address 10. US EPA ID Number G State Facility',ID <br /> Jd UGTEC.ffiP!U Hffl 1J1)It <br /> 2M N. ALAMEDA STREET H. Facility's Phone <br /> )O COMPTON, CA 90222 T 1 3 13 15 12 310-537-7100 <br /> J[1- <br /> 12. Containers 13. Total 14 Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol 1. Waste Number <br /> Z GASOLINE MIXTURE State 134 <br /> 3 G 3 UN1203 PG IIf D N G EPA/Other <br /> E V <br /> slate <br /> 00 N b. IRIS WASTE STREAM HAS BEEN QUALIFIED <br /> R FOR RECYCLING/TREATMENT ATTHE <br /> EPA/char <br /> V A a. a RDOONFACILITY IN COMPTON, State <br /> T CALIFORNIA.THIS FACILITY HAS THE NECESSARY EPA/Other <br /> PERMITS TO RECEIVE YOUR WASTE STREAM ASR <br /> W d. IED:OUR EPA NUMBER IS CATOB0013351. State <br /> Z aIIA <br /> w <br /> U EPA/Other <br /> w <br /> TJ Additional Descniptimr,for Moler ols Listed Above K. Handling Codes for Wastes <br /> Listed Above <br /> ti <br /> ac ERG #128 <br /> d. <br /> a <br /> 0 15, Special Handling Instructions and Additional format on <br /> HYDROCARBONS AND WATER 24—HOUR ENE: ENGY EHOME1 BE I# &/9,77 <br /> Z WEAR ALL APPROPRIATE 949-450-1010 (M—F seas-5pv) SITEn7—Eleven # /73 5 Ifae <br /> = PROTECTIVE CLOTHING 949-753-5826 (24—hours) 'YSoi tie, l�y2fHr •=4 <br /> 7VelcTvyv, e-rl <br /> Q 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignmeni are fully and accurate)y described abase bmla <br /> y proper shipring nae and are cssified,packed, <br /> U marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nationaPgovernment regulations. <br /> r <br /> If I am a large uanti generator,1 certi that I have o 'n lace t 1 duce the volume and taxi, of w.nt generated to the de I have dater.ned to be economical) <br /> g 9 tye fY 'P 6 p y rs ge gree y <br /> N practic.ble and that 16have selected Thep octicable method o treatment;star a or disposal Nrrenlly available to me which m mmrzes the present and Future threat ro human health <br /> and the environment;OR,if I am a small quantity geearato I have made obd 611,effort to minimize my waste generation and select the best waste...agement method that is <br /> Q available to me and that I can afford. /007 <br /> } aced T Na Signature A1pnth ay Y r� <br /> U tarpl�oo�Elkart MES( for 7-eleven I Vel G 1 <br /> w T 17. Transporter I Ackre, ledgement of Receipt of Materials <br /> Ur R <br /> A Printed/TypedName .. // / Si nalure + //' Month Da Year <br /> W <br /> 5 I -} L t) OC- 8 �.'�a,,,, 7. l^.> <br /> w <br /> 0 18. Trans rte,2 A<knowled cement of Receipt of Materials <br /> O B Printed/Typed Name Signature Month Day Year <br /> w E <br /> Q R <br /> U 19. Discrepancy Indication Space <br /> Z P <br /> — A <br /> C <br /> I <br /> L <br /> t 20. Facili Owner or O erat.r Certificalio of recei 1 of hazardous materials covered 6 Ibis manifest en as ate 19. , <br /> rinled/Typed Name Signature / `l rMjxonth Day, or <br /> DO NOT W BELOW Tkf <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 6022A 11/991 - (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br /> 1 <br />