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Please print or type. (Form designed for use on elite (12 -Pitch) typewriter.) <br />UNIFORM HAZARDOUS 1. 2. <br />WASTE Generator ID Number � <br />MANIFEST , <br />5. Generator's Name and Mailing Address <br />�q i.�s?i��:°�i E�x�car �.:�s, ins:•. <br />k ;�EL?Fti2`Ti. FadirC4[ thio' lt-recIlVh iiLSafety <br />Generator 1;2 s1 , S' L -CC` r Col I:'i'�L:� c <br />s Phone: <br />6. Transporter 1 Company Name 1" <br />i , <br />ignated Facility Name and Siteddress <br />[" <br />A%t?i'tC s )91,,. �,1 ?sitli?�'.,�...1 .. <br />,.40 <br />Phone: _ <br />U,.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />?acking Group (if any)) <br />Liquid (Used Oil,' Nixed Oil) <br />1of13. <br />\A/nPltl iiilafi�r�I mi iiinr I I e <br />has the appropriate permits to receive <br />N_ your waste, and has received the waste. <br />Ou, EPA !D Number IS <br />Form Approved. OMB No. 2050-0039 <br />ergency Response Phone 4. Manifest Tracking Number <br />00171_4230 G BF <br />dor's Site Address (if different than mailing address) <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />CAL000102/9Z <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />i <br />RECE <br />JU <br />Ilk <br />28 <br />;T�, <br />I <br />2014 <br />s and Additional Information <br />?t •,. i'xc le ' ' 3I : i.3secl hi 4'ts �d Oil �`��p�rroPriate �eisonal �'xate4titie <br />)meat <br />R'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />died, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />bntents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />Kiation statement identified in'40_CFR 262.27(a) (if I am a large quantity generator) or (b) (if] alp a;mall quantity generatorrfs true. <br />NamFf / <br />Signature �` Month Day <br />.❑ Import to U.S. ❑Export from U.S. Port ofentry/exit: / <br />onlY):' D eawa <br />fRa........ _s.. _.- . . .. <br />Month Day Year <br />k <br />Month Day Year <br />❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Number. <br />Month <br />(i•e•, codes for hazardous waste treatment, disposal, and recycling systems) <br />3. T4, <br />receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />- ; - SignatureI'— <br />