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U � <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4. an as Trackin Number <br /> WASTE MANIFEST C A R 0 0 0 1 2 3 4 5 5 1 1-800-424-9300 00950731 JJK <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Chevron 90557 <br /> PO Box 6004 - Chevron EMC Waste Desk 139 SO CENTER <br /> San Ramon, CA 94583 Stockton, CA 95202 <br /> Generators Phone: 877 386-6044 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> V oLILL. 'Go\-VT1O NS 13 <br /> 7.Transporter 2 Compan Name ,r U.S.EPA ID Number <br /> T.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Veolia ES Technical Solutions, LLC <br /> 1704 West 1st Street <br /> Azusa, CA 91702 C A D 0 0 8 3 0 2 9 0 3 <br /> Facility's Phone: 626-334-5117 <br /> 98, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(d any)) <br /> No. Type Quantity WWoI. <br /> 1. <br /> RQ, UN3266, Waste Corrosive Liquid, Basic, 122 D002 <br /> o R Inorganic, n.o.s. (Calcium Hydroxide) , 8, PG III '`O <br /> (D002) <br /> Z 2. <br /> w <br /> (D <br /> 3. <br /> 4. <br /> 14.Spacial Handling lnstuctionsandl Additional Information Wear Level D PPE, gloves, goggles, spliaah, protection (if liquids <br /> present) <br /> 1.Profile# 615570 WR2599 I ERG: 154 <br /> SO # 0015155919 <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shtpping name,and are classified,packaged, <br /> marked and labeted/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 terms of the attached EPAAclowwledgment of Consent <br /> I certify that the waste minimization statement identified In 40 CFR 26227(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> Generators/Offerors Printed/Typed Name �r op Signatu / M th Day Year t <br /> r= ♦ G� i"` CTGHf.. � "7 <br /> 1 16.International Shipments <br /> Z ❑import to U.S. ❑Export from U.S. Port of entry 'G <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans r 1 Printed/Typed Ne' Signature Month - Day Year <br /> H 4 r'I�'1 Q XCI 1 <br /> Z Fra sports Printed/Typed Name Sin re- <br /> � 9 Month Day Y ar <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue ❑Partial Rejection ❑Futl Rej.Won <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> W FacUty's Phone: <br /> W i8c.Signature ofAftemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> W19.Hazardou ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. 3. 4. <br /> 20.Designat Facriity r or Operator.Certification of receipt of hazardous materials covered by the manifest exceotd in Iterp 18a <br /> Prinled/lyped Name �! t Sigrmture onth Day Year <br /> EPA Form 8700-22(Rev.3-05) Ftevious editions are obsolete, <br /> nF& AT. FACILITY T ES !NATION STATE(IFR UI D) <br />