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1 <br /> ,l <br /> Please print or type. Form designed for use on elite 12 Itch D T S C. 0 2 719. 2 03 2 <br /> ( g (12-pitch))typewriter.) Forth Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone7010957720 <br /> .Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 0 3 3 9 6 3 1_L6110 749-1390 JJ K <br /> 5.Generato/s Name and Mailing AddressATt DEBBIE VASOUE -neratoes Site Address(i1 different than mailing address) <br /> STOCKTON METROPOUTAN AIRPORT <br /> 5000 S AIRPORT WAY <br /> STOCKTON CA 95208 <br /> Generator's Phone: 2 0 9 4 0 8 - 4 7 0 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NRC Emironmental Services C A R 0 0 0 0 3 0 1 1 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi hated Facility Name and Site Address USEPA ID Number <br /> Grosby&Oveiton,Inc. . . <br /> 1830 W. 17th Street <br /> Long Beach CA 90813 <br /> FadfitysPhone: 562 432-5445 C A D 0 2 8 4 0 9 0 1 9 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WWol. <br /> 0: ' UN 1993,WASTE FLAMMABLE LIQUIDS,N.O.S.,(GASOLINE, 331 DC01 001 <br /> o WATER).3,III <br /> 9 002 DM G <br /> w <br /> W 2. NON-RCRA HAZARDOUS WASTE,SOLID �' 352 <br /> (DEBRIS CONTAMINATED WITH PETROLEUM HYDROCARBONS) ' <br /> 0 0 1 DM 6350 P <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> WEAR PROPER PERSONAL PROTECTIVE EQUIPMENT, JOB/PO# 79890 <br /> NRC 1605 FERRY POINT, ALAMEDA, CA 94501 <br /> 9B1) PROFILE# 64370, 2X55G 952) PROFILE# 57426, 1X55G <br /> SS15vI,, A515- <br /> 15, <br /> . GEN ERATOR'SIOFFEROR'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 /> marked and labeled/placarded,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 /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowiedgment of Consent. <br /> I cerlity that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> rnemtors/Offeroes Printed/Typed Name Signature Month Day Year <br /> ��itt l 16 -t a cit O 20 <br /> 16.International Shipments <br /> I— ❑Import to U.S. El Ecport from U.S. Port of entry/exit: <br /> LE Transporter signature(for exports only): Date leaving U.S.: <br /> U rY 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped NameSignature Month Day Year <br /> (� I 6 ZQ r <br /> Z <br /> Transporter 2 Printed/Typed Name Signature Month Day Ye <br /> UA 3 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: Month Day Year <br /> LO 16c.Signature of Altemate Facility(or Generator) <br /> r <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> 0 -T+l 1, r 2. 3, 4. <br /> 20.Designated Facilityor tor.Certification of receipt of hazardous materials covered by the manifest except as noted in ItN 18a <br /> Pdnled/ryped Name Signature Month Day Year, <br /> ai 2 rUl <br /> EPA Form 8700-22(Rev.3-0revious edi ns are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> 11685.1417 <br />