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C. 03 4 . 201 C, <br /> Please print or type.(Form designed for use on elite(12-pitch)typewnlec) Fon Approved.OMB No.20504039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mantfest Track! Nber <br /> WASTE MANIFEST IC-AL-000-N1600 , 91&371.574710156t"8' 301 i <br /> 5.Generators Name and Mailing Address Generators Site Address(d dleemm Clan mailing address) <br /> y4 W �Rk L► 11 l(e <br /> Generators Phone: <br /> 6 Transporter 1 Company Name - U.S.EPA ID Number <br /> RAMOS ENVIRONMENTAL SERVICES INC. CA,0044003596 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Desgnated Facility Name and She address RAMOS ENVIRONMENTAL SERVICES INC. U.S.EPA ID Number <br /> CAD044003566 <br /> 1515 SOURIVER RD. <br /> TH <br /> WEST SACRAMENTO,CA 95691 <br /> 91&371-5747 <br /> Fadliys Phone <br /> gra 9b.U.S.DOT Desorption(including Proper Shipping Name.Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packirg Group If any)) No. Type Quantity W Wo1. <br /> 1, NON RCRA HAZARDOUS WASTE LIQUID (OILY WATER) .8_ q 223 <br /> K moi+ <br /> fo -�- aso G <br /> z 2. <br /> Ci <br /> 1u <br /> 3. <br /> 4. <br /> 14.Special Handling InsWNons and Additional Information p <br /> 9MDLERS TO BE TRAINED ANO USE APPROVED PPE. / S�V a <br /> AI <br /> E.R. CONTRACTOR: RAMOS ENVIRONMENTAL SERVICES <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the coments of tins consgnmenl are fully and accurately described shore by Me PmD r shipping me,and arra classified,packaged. <br /> marked and IabeleNplacarded,and are in all respects in proper condition for transport amording!o applicable international and national govemmentol regula ons.if etrpo hipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAohnowledgment of Consent. <br /> I cemy that the waste minim'oadon statement identified In 40 CFR 262.27(x)i I am a large quantity generator) r(b)(d I am a small getre )is <br /> G tie ors/Oaerorsn Rin yped N S arae Monty Da Year <br /> YAYD n <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export ft.U.S. Pon of entry/e <br /> Transporter signature(for exports only): Date leaving U.S.. <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PdntedRy Name g Month Day Year <br /> Q 72O <br /> a <br /> N <br /> QTranspolter 2 PruntecliTyped Name Signature Month Day Y <br /> K <br /> 1-- <br /> 18.Discrepancy <br /> Its Discrepancy IndioelMn Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> Ill Altemats Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> IQi Fachys Phone <br /> w 1i*nal of Alternate Faulty(of Generator) Month Day Year <br /> 4 <br /> z <br /> H19,Hazardous Waste Report Management Method Codes Cre.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 7. 2. 3. 4. <br /> 20.Designated Faulty Owner or Operator.Certifiraeon of mo ipt of hazardous materials covered by the man9est except as nded to Item tAa <br /> 1 <br /> PrhXtyped Name SgnawreMonth Day Year <br /> S61 <br /> 103o G <br /> EPA <br /> Forth 87 22(Rev.3.05) Previous e ons are obsolete. DESIi ED FACILI TO DESTINATION STATE (IF REQUIRED) <br /> 12241.0754 <br />