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02/06/2007 10:23 FAX <br />Please print or type, (Form designed for use on elite (12 -pitch) typewntec) <br />VALERO ENERGY U003/006 <br />i• <br />v. u w �11N11JO1G W�� DESIGNATED FACILITY TO GENERATOR <br />y <br />UNIFORM HA7ARDOUS i. Generals iD Number 2. Pa 1 of 3. Emergency R �� Approved. OMB No. 2050-uuag <br />age rg ncy esponse Phone k Manifest TrzcNirg Number <br />WASTE MANIFEST . .. .- .. .. _ _. .. _ : - 3L 1-... 001182114 <br />7 JJ K <br />5. Gertestors Name and Mailing Address Generators SleAddress (if oirterenl than mailing adMess) <br />09: inlTHR -- <br />A1,4FCRr: ,_;; TYK <br />Generabrs Phone: <br />6. Transporter 1 Company Name <br />FCOIOp'y CortraI :f`LUStrI•_5 U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPAID Number <br />B. Cie6ignaated Faplity Name antl Sile Atldress <br />crio y'r l.. n„O'ri 1rrdt;;S:PS U.S. EPA ID Number <br />255 Parr D o>_;ievgnj <br />Richnund <br />FacilitysPrima: 0111 ii:}.. 1g5% <br />- <br />go. <br />9b. U.S. DOT Description Inducing Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />snit Packing Group (if any)1 <br />Quantity <br />WtNd. <br />13. Waste Codes <br />Na. <br />type <br />I <br />1 NOrFRC.= Rs <br />F1 <br />w <br />C7 <br />3. <br />4. <br />14 $pedal HaMI I and Am@oral lnlmmmron <br />.. rmy ...m to -_EC <br />-1 3.3E # <br />4:c)kR 6nc=p -GrE 74-11 ._.:.^- r... -^ .. _� r ed .— _. <br />waw, _r_::.. <br />15. GENERATOR'SIOFFEROR'S CERTIRCATION: i hereby dwwe Nat Ne contents of this mnsignment ars N4 brut aommtely described above by the proper shipping narne,�ard are tlasdfied, packaged, <br />marked and labelecUplaarded, and are in all impacts in proper condition for banspod so,noi g to appsmo@ intemaeaal and national governmenlai regulations. If export shlpment and I am the Pdmaty <br />Exporter. I airy that the mntemts of Nis mnslgnmenl mnfarm to the terms of the attached EPA Acknowledgment of Consenb <br />I cerbry that the waste minimization statement identified In 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (dl am a small quantity gemun,”) is true. <br />Generalcest06erors Printedryped Name Signature •, Month D Year <br />ri <br />in. International Shipments <br />❑Ir <br />mpprltuuz. � 1 ❑Export from U.S. Porlotenry/exa: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17.TlanspaterPcknonledgmmtof Remiptof Materials <br />� <br />p <br />T ' 1 i>dntedlT r <br />e A� <br />CNY'..7 •' Tom. /,(�t .'� ^^ ,,rj Month / /Year <br />- .� 1f7 <br />h <br />- ✓ ,��.✓�1G."tJ <br />zQ <br />Transponar 2 Prinretl17yped Name Signature - i Mffontth_ Day Year <br />fid <br />18. Disaepanry <br />18a. Discrepancy Indication Space Quantity ❑ T ❑ Residue Reject), <br />Type Partial Rejection ❑Ford <br />Manifest Reference Number <br />18b. Alternate Facility (or Generalor) <br />J <br />U.S. EPA ID Number <br />ES <br />LL <br />Facility's Phone: <br />w <br />16c. Signature of Alfemate Facility (or Generator) Month Day Year <br />G <br />z <br />N <br />19. Hazardous Waste Report Management McNod Codes i.e., c0des )r hazardous waste treatmenk recycling systems) <br />( disposal, and red di <br />D <br />1. <br />2. 3. <br />4. <br />20 Designated Facility Owner m Opera)r. Certification of receipt of hazardous materials covered by the tnamfesl except as noted in item 18a <br />1 <br />Pnmeorlypect Name Signature Month Day Year <br />CO(. <br />C .... Y>M 2Z � .. <br />v. u w �11N11JO1G W�� DESIGNATED FACILITY TO GENERATOR <br />y <br />