Laserfiche WebLink
Please pnnl or type.(Furrndas grand for use on villa(12-pitch) rilar.l FormApp(aved.OMB No.20510039 <br /> UNIFORM HAZARDOUS 1-Genoralor ID Number 2-Page t of 1 finergrnry Response Phony 4,Mamilest Tracki�n+g kumhar <br /> WASTE MANIFEST C A T 0 0 0 6 18 6 3 i 1 (1100)424-9300 017 TJ 9 ,2 9 0 JJ K <br /> S.Generator's Name and Malfing Address Genoralnr's Silo Address(If difforent than mailing address) <br /> TESORO STOCKTON TERMINAL <br /> 3003 NAVY DO <br /> ST&WON r.A 95206 <br /> Generator's Phone: 714 POI-1640 <br /> 5 Transporter 1 Company Name U.S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES 6 A D 0 2 82 7 7 0.3 6 <br /> 7.Tranipodor 2 Company Noma U.S FP?,ID PILI MNf <br /> f►Um'EnOityWrap aM SAnlvfc're U.S EPAIDNuwntrgr <br /> DEMENNO/Kr.RD00N <br /> 2000 N ALAMEDA STREET <br /> COMPTON CA 90222 C A T O S 0 0 13 3 5 2 <br /> ga 9b.U.S.DOT Descripflon(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 Wt.Nol. <br /> t NON-RC RA HAZARDOUS Iii•UQ(IID f USED CIL/MIXED(4I_) 221 <br /> 0 <br /> ' DM 0 I <br /> W <br /> Z <br /> W I <br /> 3 I <br /> r4. <br /> 14.Special Hardlmg mswdlons and Addoonal information <br /> EMFRGENCY CONTACT CHEMTREC 1-804424-9300 WOES TERMINAL CERES CS `PROFILF_N 981 4303486 USED UIL/ <br /> MU(EO Ori. • "APPROPRIATE PPE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare[hot the contents of Nis consignment are fully and accurately described above by the proper shipping name,and are classified,packeged, <br /> marked and labeledfplacarded,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 terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(d1 em a small quantity generator)is true. <br /> Goneralorsloftews PflntedlTyped Name SignatureMonth Day Year <br /> 1 16•Intemallonal Shipments <br /> 1— ❑Import to U.S. ❑Export from U 5. Pad of entrylexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporiarAckrlowledgment of Receipt of Matorials <br /> TrerMpoctee I PaMedfryped Name Slgnalwe Wroth Day Year <br /> Q <br /> cL <br /> N <br /> Transporter 2 PrintedlTyped Name r Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quanf Type n Residue 1 I <br /> dy rl ❑Partial Re ecfian ❑Full Re'eclion <br /> hlsnifost Roleronce Numbor <br /> I 81 AUemate Fac flly Jar Genolator) U.S.£PAID Number <br /> U <br /> M Faollys Phone: <br /> Ik.Srg 1uio atAltornalo Fa6bly for Ganeratgf) hforrih pay Y@ar <br /> a <br /> z <br /> 19 Hazardous Weste Report Management Method Codes(i.e.,codes for hazardous was le treatment,disposal,and recycling systems) <br /> G 1 2 7. 4. <br /> 20.Dosignaled FecRdy Owner or Oponulo!:Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br /> ranted+yped Name I <br /> signokye Mmh My year <br /> Ll <br /> L•PAFnrm 8700,22{Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />