Laserfiche WebLink
Please print or type.(Fomi designed for use on elitel2- itch typewrill , .F -' Form Approved.OMB No.2650-0039 <br /> UNIFORMHAZARDOU3 1;GeneralorlDNumher ^2.Pagel of 3.Emergency Response Phone ° A ManNest Tracking Number <br /> WASTE MANIFEST C;ARO0tg14203. I ($U0)4171 9300 004641465 FLE <br /> 5.Genealofs Name and Maflmg Address , General siteAddress(a ciierent than mailing address) <br /> Tesoro Tewro Stoiion 68151 <br /> P.O. Box 80730 35 N Cherokee Lane <br /> Rr rwho Santa Margarita, CA 92688 -r Lodi, CA 95240 <br /> Geneaws Plane: <br /> .Transporter I Company Name U.S.EPA ID Number <br /> SELSFIIR CARU0L7133913 <br /> 7,Trans r2uDwa%1iI1Iw1%0Lw1 V LMLIPU.S EPAIDNumber <br /> 8.Designated FaoSy Name an 2014 U.S.EPA ID Number <br /> Dahlernrro Kerdoor, L IY ENVIRONMENTAL <br /> 20aD N. �NMENTAL HEALTH DEPARTMENT CATO 0013362 <br /> Corn ton, <br /> Faardyrs Mane: NEW (310)r3 37-7900 <br /> ge. Sb.U.S.DOT Description(Including Proper Shlppng Name,Hazard Class,ID Number, 1D.Contelners 11.Total 12.Unit <br /> HM and Packing Gaup(gany)) No. Type ouanuty WtNol, 13.Waste Codes <br /> o X 1' LIN1203, O asolirn Mixture. 3, PG 11 f f� 134 <br /> W 2. THIS WASTE STREAM HAS BEEN QUALIFIED _ <br /> FOR RECYCLINGITREATMENTATTHE <br /> 3 CALIFORNIA.THIS FACILITY HAS THE NECESSARY <br /> PERMITSTO RECEIVE YOUR ViASTE STREAM AS <br /> 4 OUAUFIER OUR EPA NUYfliER IS CAT08001339 <br /> 14.Special Handfug lnstrudrm <br /> bns and Additional Into 'AT-AR �R r p ' <br /> aLL,aPRUr r fArl. Irl ti. 1. Ci. d <br /> ER129 A05882 <br /> Gasoline <br /> pt�GTEL;TlVE Ct.1:7THI�LG. 20$B82 <br /> Gasoline&Water TESORO C(:N: <br /> � � � rs16330 <br /> 15. GENERATORBfOFFEROR'SCERTIFICATION: I hwebydedarethat the contents of this consignment are Poly andacaraley desa'bed above by the proper shipping name,and are dasAW.packaged, <br /> marked and labeled/placarded,and are in all aspects In proper centlieon for tanspnt according to apprrabfe international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certy that the c9nlents of Rds consignmentconarm to Dn terms of the attached EPAAduavaigment of Consent. <br /> I certify Ilue asfe min8n7ation statement Identified N 40 CFR 26227(a)(Alam a large quantity generator)or(b)(d l am e sma, apbygenerator)Is We. <br /> nerato s! enc s PrintediTyped Rama— gra ura �( Monthy ear <br /> (_any Moothad of PI I or,beh,lf of generator � �-•- � l� <br /> -.r 18.Intema8onel Shipments <br /> El Import to U.S. LJ Expert from U.S. Pod ofentryletdl: <br /> ' <br /> Trarranowlers nature for ex ds only): Deteleavl U.S.: <br /> 17.TranspoderAckncxledgment of Receipt of Materials j• <br /> Transpotter l Pr/in�t yped Name A r pmare on ay Year <br /> Tanspoder2Pdntual Typed Name - Sgnalure Month uay Year <br /> 18.Discrepancy <br /> 188.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejector <br /> Manifest Reference Number. <br /> 19b.Niemela Famliy.(or Generator) U.S.EPA ID Number <br /> "Q- Faril 's Phonvell S, <br /> Ws <br /> SignalureefAkemale Faalily(or Generator) Month Day Year <br /> cN"d 19.Hazardous Waste Report AlarrzgemealMemod Codes(i a.,codes for hazardous vmsle treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Oxnera Operator.Certieadon of receipt ofhwardaus materials covered by the manifest except as noted in Item 18a - --j <br /> Pdnfed7f Name r•-.-_ .-..--� S�paldre r ..«,�--•.• ^�^— -----. Alanlh Day Year - <br /> EP arm 87 -22(Rev.3-05) Prevbuseditio are obsolete. Cj-' ` DESIGNATED FACILITY TO GENERATOR <br /> i <br />