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00198. 2144. <br /> Please print or type,(Foran desi ned fiaiiuse on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS t.Generator ID Number Z Page 1 of 3.Emergency Response Phone 4.MenReel TrxMrp Number <br /> WASTE MANIFEST CAROW144410 1 9494%9-3706 Q Q Q 7 6 8 7 3� F L E <br /> 5.0enerator's Name and Mailing Address Generators Site mannes;(a diBeent than mailing address) <br /> USA Petroleum Corporation USA 0835 <br /> 905 Rancho Cel Blvd. 2705 Country Club Blvd <br /> Newbury Panic.CA 91320 439-460-52001 Stoddon, CA 95204 <br /> Generators Phone: <br /> Transporter I Company Name U.S.EPA ID Number _ <br /> BELSHIRE ENVIRONMENTAL SERVICES, INC. I CAR000185175 <br /> 7.Tanspoder 2 Company Name -- ---- -- - - - - - - U.S.EPA ID NumberiAn - - - - <br /> -- 'tN' 0IL <br /> e. ignated F crIM Name end Bite Ad ress U.S.EPA ID Number <br /> US Ecology, Nevada Opeiaborrs _- <br /> Hiovv 96, 12 miles S. of Beatty. -, NVT330010000 <br /> _. <br /> Fa�s , fJv 89003 77653.2203 - - <br /> ga 9b.U.S.DOT Description(inciuding Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM' acrd Packing Grcup(Hany)) No. Type Quantity WI.Nol. <br /> W x t. Solids, Containing Flammable Liquid, n.o.s.,4.1. UN3175, PC 362 <br /> 1. p01 A►r 5�� P <br /> z 2 <br /> W <br /> 3. <br /> ,7 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information WEAR ALL APPROPRIATE BES1138199 " - <br /> ERG# 133 '` PROTECTIVE CLOTHING <br /> - <br /> 0� -oi -� - 03N � <br /> 15, GENERATOR'SPOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fullyand accuately described above by the proper shipping name,and are deasified packaged, <br /> _ marked and labeled/placarded,and are in all respects in proper condition for transport according b applicable inamalbnal and natiorel gavemmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the wntents of this consignrrent conform to the terms of the attached EPAAcknuMedgment of Consent. <br /> I certify that the waste minlmlzation statement identified in 40 Cl 262.27(a)(R I am a large quantity generator)or(b)(J I am a small ne argil is true. <br /> GensicatoesiOffences PirintedliTyped Rome— sunature Month Day ear <br /> Larry Moothart of BEST on behalf of generator , 107 <br /> 16,International Shipments ❑Export hen U.S. Rof <br /> _ 11 Import to U.S. entryfexit <br /> Transporter sature for exports oral : Oate Is no U.S.: <br /> w 17,Tansp"Acknowledgment of Receipt of Materials <br /> K Transporter l Printed Name signs n ay Year <br /> 3 2l 07. <br /> Tansponer2Pdnted Iy _- ame- - -� -- - nature x n - — ay- ear"- <br /> U t1. Gf0/ Of►ef� .�,� 03 � a <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Panel Rejection ❑Fud Rejection <br /> Mandl Retinal Number. <br /> 18b.Altemale Facility(or General U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> W Fact 's•Phone: <br /> 8c 2 S' a Fadlity(or Generator) -r Month- Day._ Year <br /> 1 a .'�a"f'1f0�f�'E�.__. . . . --- � - - <br /> N <br /> 19.Harardeus Waste Report Management Method Codes(i.e.,codes for hammous waste treetrcent,disposal,and recycling systems) <br /> l. <br /> .. // _jT7 7 3. 4._j 7 7 3.4. <br /> -- <br /> 20.Designated Fal Ownef or Operator:Cenficatipn of recolpl of hazardous materials covered by the manifest except as noted in Item IBa <br /> PnnlerllTyped 1/ / / Signore Month Day Year <br /> EPA Form 870022(Rev.3-05Previous eddmns are obsolete. .. ,p rh D FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 10166.1778 �/ <br />