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02/06/2007 10:22 FAX VALERO ENERGY IM 002/006 <br />Please print or type. (Forth desgned for use on elite (12 -pitch) typewriter.) <br />PC— A,,,,.,,,,en nsac hl„ nncr>_nnao <br />t:rA conn 67Du-r2alSev. a -us) IrreHous eatlpns are opsrnere, , - DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response above <br />4. Mansest Tracking Number <br />WASTE MANIFEST _ _ - - _ <br />=1 <br />001382.396 JJ K <br />5. Generator's Name and MahingAddress Generators Site Address (if different than mailing address) <br />it 4 <br />Generators Phone: <br />' <br />6. Transporter l Company Name U.S. EPA ID Number <br />- <br />7. Transposer 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Faalitys Phone: -.� <br />A <br />ga. <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Gass, ID Number, <br />10. C2m-T s <br />11, Total <br />12. Unit <br />HM <br />and Padding Group (d any)) <br />Ouantiy <br />WWd. <br />13. Waste Codes <br />No. <br />Type <br />aO <br />_ <br />'r? <br />K <br />W <br />'11 JIi0 <br />F <br />Z <br />2. <br />W <br />U <br />4. <br />14. Spedal HandfiInsfNctlons and Additional Information <br />crrl'Y �r'" - '?uIC; . T"A Ni:: :'- _-s e.9G <br />�r.'r _h�r$R._E Nc`.; ,iri�r.TaC •.=[.N"'G ., rl-: n ��.._rr 3t�r{..=:'ZN_.. _.. <br />:ATE_ <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the comenb of ads mnsgrmenl are Nay and aoxmdely described above by the proper shipping name, and are classified, pedmiled, <br />marked and IawleNplacarded, and are in all respects in proper condition for oanspon according 10 applicable intemation adand nadonsl governmental regulations. II BVort shipment and 1 am dile Primary <br />Exporter, I car* that the contents of this 00psgnment confomn to the terms of the attached EPA Acknowledgment of Consent. <br />I ca i fy that the waste minimization statement identified in 40 CFR 262.27(e) IN i am a large quantity generator) or (b) (RI am a small quanaty generator) is rue. <br />errs PnntedrTyped Nam <br />QYearON <br />Month <br />k�`k l(DJay <br />L <br />Y <br />16. International Shipments <br />❑ 1, +j , <br />Import to U.S. ❑ Export ham U.S. Port ofentry/eut <br />Transporter signature (for exports orgy): Dale teeing U.S,; <br />W <br />17. TransporterArknoMadgment of Repeat of Ma(eniala <br />Transported Na Signature -^ 101 7'PaNy Year <br />- <br />li� <br />a <br />Transposer 2 Pdnteduyl e t Name Signature Mad Day Year <br />K <br />18. Discrepancy <br />18a, Discrepancy Indication Space ❑ Ovantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rate lkin <br />Manifest Reference Number. <br />its. Alternate Faafiy(or Generator) U.S. EPAID Number <br />J <br />U <br />LL <br />Fadlilys Phone: <br />w <br />1Se. Signature ofAllemale Facility for Generator) <br />Monro Day Year <br />4 <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste aeabnent, disposal, and recycling systems) <br />C <br />1. <br />2. 3. <br />4. <br />20 Desgmted Fadgy.Owner w fhwalar Cad mtidn of r Otof hazardous matenals covered by ds mar frit except as nded In Item 18a <br />1 <br />Pnnted/Typed Na esti_._ Signature -' - - Month Day Year <br />3 r fl <br />t:rA conn 67Du-r2alSev. a -us) IrreHous eatlpns are opsrnere, , - DESIGNATED FACILITY TO GENERATOR <br />