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,%W <br />Fleasepenlorfype.{Form tlesgned for use onelM(12-pich)l typewriter.) I4 <br />Fnmf AnnrnreA 111UR Nn pR50J01'an <br />EPA Foamn 870D-22 (Rev. 3-05) Yrevous sardine are cos"te. <br />DESIGNATED FACILITY TO DESTINATION STATE OF REOUIRED) <br />UNIFDRM HAZARDOUS 1. Generator lO Numberq r <br />2. Pagel of <br />3.Emarpanry Response Pmm�e <br />LMarrNeat incidny Number <br />WASTE MANIFEST CARGO 186668 <br />1 <br />@OO)368-4778 <br />015348399 JJK <br />5. Generitets Name and Macy Address GePareWs Site Address (it different Nan medmg address) <br />CONWIVITY FUELS 809-C 5NEDEKERAVE <br />809-C 5NEDEKER AVE <br />STOCKTON CA 95M STOCKTON CA 95109 <br />Gereatoes Phone: 209 468.4815 <br />E. Tramp rew 1 Company Name US.EPAIDMakwr <br />ENVIRONMENTAL RECOVERY SERVICES CAR 0 0 0 1 8 8 2 0 1 <br />7. TrsaDoder2 <br />Company haml U.S.EPAIDNumber <br />8. <br />-noted Fanly Name aw Sib Address U.S. EPA ID Number <br />HINECO <br />1007 VULCAN ROAD - MASKELL <br />BENTON AR 72015 <br />Fadfi <br />a Phooa: 1501)776.9089 ARD 9 81 0 5 7 8 7 0 <br />ga. <br />90.US. DOT Desorptim CmUudog Proper Sopping Name, Hazard Class, ID Nummr, <br />10, Lana'erars <br />11. Taal <br />12. Lim <br />I <br />HM <br />ab Paddrg GrasDlsarM7 <br />Quantity <br />WtArq. <br />13. Waste COGS <br />No. <br />Type <br />x <br />1' NA9077, HAZARDOUS WASTE SOLID, N0.5., 9, PGIII (NETHANOL, <br />FOM <br />TOLUENE) <br />Z <br />D ASI <br />16-0 <br />p <br />E P �F 4� <br />I <br />a AUu 0 Ya 2016 <br />4. ENVIES-. , ._. <br />HEALTH '. ;; ".'nrMAEN€ <br />14. S1e601 Handing InMN4ma and AeeaimN Inkama000 <br />yy� <br />9811100&11223-50LIO DEBRI5-LAB WASTE 2'Xyb.� ERGd7: 981. 171 " ERS W.O.H 121247 -VA" <br />24 MR EMERGENCY CONTACT: ENVIR05ERV <br />15. GENERATOR'S!OFFERORSCERTIFICATION: I hereby declare(hat me mntentiit,*=nsv,,am, are tall,wda=ra:ey Gescroed adore by me proper sipping name, amabrdassred, packaged, <br />-I-marked <br />asd abeledi"carded, and are n as respects M proper mnd:5an for YarapalaruNi'q fo aWbab a imemadonaiand nahmal govemmmal reHdaOOns.I/asport Nprnanl and l am the Prinary <br />Eabdr'ar, t why Uat erecunans ofthis crosignment=,&omlto the termsoftheatgtlwd EPAAcknoaledge esdofGencor. <br />a+ey Oat 111ewashngrinel8fsln satementidmtl5ed in 40CFR26227(a)(f I ame large quarittygeneracr)or(b)Cd emasmellquantiygeneraaDb hue. <br />Ge slOaeroh PrinkC7fyped Name slgMalw Month Year <br />6 <br />F <br />16. Mernaeonal Snp ms <br />❑hnporlto U.S. ❑FJIpprl Qom V.S. Portotmtryletiz <br />Transpwbr signature (for e>morm o 1f): Date leavirq LLS.: <br />W <br />111 Apknpwedgmam Rem'A: C' �eria!i <br />Two )PMIedRyyedN Signa„ V <br />Iss <br />..._/j. Day Year <br />y <br />Q <br />Tara;ZFIftedTyasE Na+e graWre52 Monts oar <br />is Discrepancy <br />1 Ba.DixrepanrylrbicjiiWSpace ❑ Q.nf ry Type ❑acs=.e ❑Pa'lal Rejection ❑FrAlldjaOlm <br />warifes'. Refererce N; -Ger <br />160. A)bma!a FaWry(or Generatoy U6.=PA D NumJer <br />J <br />U <br />FacWs Phone: <br />Ow <br />18c. Signature oWemats Facility (or Genenbr) MonVi Day Yeas <br />Q <br />z <br />H19 <br />Hazardous Waste Report Management Method Codas(re.. codes ar hazardous waste lreatrnenl, Qaposal, and rung systems) <br />0 <br />t. 1+0 � <br />2. <br />3. <br />4, <br />20. DeaiynaNd Fscsty Oamer 7 Opea= CwtiEcaOun m'wupt of hazardous ma"6 ddvmrad by me maraca exupi -".ow A Item 1Be <br />111PmWeyded <br />III <br />Nam Sigmar 16Akntl+ a'yT Year <br />EPA Foamn 870D-22 (Rev. 3-05) Yrevous sardine are cos"te. <br />DESIGNATED FACILITY TO DESTINATION STATE OF REOUIRED) <br />