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Please print or type. Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.N(a ife5t TCac gtJupr qFN„g
<br /> WASTE MANIFEST CALOV,10441.'3ti4 I ::ErB Uti i I'i£K} ! f °� ' F4 G BF
<br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address)
<br /> INNCI fANONS GALII:01RINIA
<br /> 'I:3`; HVVY cis
<br /> .TQC K I(_tN,CA 952 ib
<br /> Generators Phona'I;;!•639-14J10
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> PiIV11 Ct.iG.�d`I VALLEY 1rVAS11-4 OIL, INC.
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> �7;1bI(,Y(, N 51"f-C:IAL-1Y VVA�;l E S(X.-U I INC i I0,q24-
<br /> 8.
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<br /> 8.Designated Facility Name and Site Address,•. U.S.EPA ID Number
<br /> "'::;t `_:i�IUii}It"Y' I;:MJIfCOPJJMEIVIAt_I':9i�N�17 C.%I'hil:,if�+tlrl,Ll..(: hitlLl9RL1ti.�Fe3:ifl
<br /> 2095I4I:"1NLAN()S r) . EAS r
<br /> FERNLIF-Y,NV K?4011
<br /> Facility's Phoned lta-57`r-12760
<br /> ga. 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(if any))
<br /> No. Type Quantity Wt.Nol.
<br /> 1. (113266,WAFtTF 0e7RR0,S1VF I.tCA111),BASIC,,iAK'iRC fdi(';;N O; , D602 1141
<br /> O r+ ) r Iry .'•a3I,. F'I.3(`r tfB-i+..•hd�f�4.iTfih3k'_t,. ,d•-T€afc��:R.I3�UY,YY.IC.r-0.t.YT+fi,al F:I"..:
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<br /> w 2. C2G�j1447,fif),-FVJeT,E:-�I�I�t'��0VkGG4-4i:1C-".f�,t� okCatd-fS;•E'G1 tt-^ Com-* litiCiK. 7.04 ,
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<br /> 4.
<br /> 14.Special Handling Instructions and Additional Information
<br /> s. 4'4s+34 t.,itr :iirtiltCrREIVI1l24ary k:Ft. r# fit "•'•f+�jfij:Jr , # i[iytapf3 i?>. :oF'1:3ZEr_ ii �Ict, 4,01-
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<br /> 15. GEN ERATOR'SIOFFEROR'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 EPA Acknowledgment 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 /> Generators/Offerors Printed/Typed Name Signature Month Day Year
<br /> 16.International Shipments
<br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit:
<br /> ? Transporter signature(for exports only): Date leaving U.S.:
<br /> w 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printed/Typed Name Signature F' Montp,' Day Year
<br /> L
<br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year
<br /> H
<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space El
<br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> J
<br /> U
<br /> LL Facility's Phone:
<br /> H18c.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. Notice: State of California requires
<br /> generator to photocopy and mail to
<br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18� DTSC with 30 days:
<br /> Printed/Typed Name Signature P,O Box 400
<br /> Sacramento, CA 95812-0400
<br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPT
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