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0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No:2050-0039 <br /> UNIFORM HAZARDOUS Generator I Number e+ , 2.Page 1 of _3.Egiergenc Response Phone 4.Manffest Tracking Number <br /> WASTE MANIFEST � S 1 1 9 - (3L�1) «iY 00814731-5w; J J <br /> 5.Ger for s tap). Generator's Site Address(if different than mailing address) <br /> r <br /> JIM AUTO PLAZA <br /> TRACY CA <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name Ut,$.F3A INber, 7 7 0 3 6 <br /> AS"YEWR4"NTAL�RVCTS FA <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi nated Facili Name and Site Address U.S.EPA ID Number <br /> C"" NC !KE4?C 'iON. .. <br /> XMN-Al..ANIF-tom TRE -i t~ A T 0 0 0 0 1 3 3 5 2 <br /> `'OWTOW CA 90 <br /> Facility's Phone: I� <br /> ga 9b.U.S.DOT Description(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 /> 1. <br /> oArm,-FLA LE LoC 14L?, N G (01IMS,DIESEL)«3>LIN 1903,P43 III M <br /> Z 2. <br /> W <br /> 3. <br /> I I <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 'P <br /> jE �Y CONTACT:((4EMIRM 1 0-424- MER00 901 : 128 P4 OALE#101 .3`1".s _ .:, , <br /> OO <br /> A11C4 R APPROPRIATE PERSONAL PROWV*.EQUPNENT <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/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 EPAAcknowledgment 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)(if I am a small quantity generator is true. <br /> Generatoes/Offeroes Printed/Typed NameSignature Month Da Year <br /> J 16.Intemationai Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: --- - <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LM 17.Transporter Acknowledgment of Receipt of Materials <br /> F' Transporter Month Da 1 PrintedfTy ed Name .� Signature � y Year <br /> p <br /> 0 <br /> 0 <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> �a Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />