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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 Phone4.Manifest Tracking Number <br /> WASTE MANIFEST �At i0 X3+'1 f� a za-9s n 0 6 4 1 8 G 7 2 GBF <br /> 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Pacific Ethanol <br /> 3$M Pavy Urive <br /> 6toCkton, (A J62W 209-851-4077 <br /> Generator's Phone: <br /> 8,Transporter 1 Company Name U.S.EPA ID Number <br /> fiernge-Crystal (;Jean. Inc ILRUUUI3OW2 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US EGULt.Xi Y <br /> FEW Y ab <br /> beatty, NV 89UUS 800-239-3943 NV J:53U01 UUUU <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No Type Quantity WLIVaL 13.Waste Codes <br /> 1 N Fi('HA haFardpUl..Wsister-noUd,4EMpty UrumsQnce 512 <br /> 00 (,nyltairling nil) <br /> w <br /> LU ;�{{'�l - '7A 1, r�r� y I r <br /> (, J1, {\Ji.l1 1101.t1,41V1t� :Y11•:u.�., dV11w, ,JllD <br /> 3. <br /> tale-RADII-J+ r: f dge) r. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> yb-1) errlpty c1runle W70'129300-21MI08 ERG#171 9b.3)oiiy aludga WJ/01315Y0-22213 ERG#171 <br /> 9b.2) oily debrie#070128300-0466 ERG##171 9b.4) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expgrjshipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generalofs101feroes Printedrryped Name / Signakrre Month Day Year <br /> 14 <br /> 16. ntemationa Shipments <br /> t= ❑Import toU$. ❑Export from U.S. Pod of entrylexit: <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 Month Day Year <br /> Transporter 2 Printedffyped Name Signature Month Day Year <br /> l- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue El Partial Rejection ED Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Fadritfs Phone: <br /> W 18c.Signature of Alternate FaaTity,(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19,Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1, 2. F <br /> 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 /> PrintedTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> I <br />