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Please print or type. (Form designed for use on elite (12•pitc ) typ writer•) <br /> Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4. Manffesl Tracking Numbar <br /> WASTE: MAN)FEST C A L 0 0 0 3 5118 3 1 800 4249300 018 2 7 2 7 6 JJ K <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> TRACY FORD - 231695 <br /> 3500 AUTO PLAZA WAY <br /> TRACY CR 95304 <br /> Generator's Phone: z 209 835-4821 <br /> 8. Transporter 1 Company Name U.S. EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES C A Q 0 2 8 2 7 7 0 3 6 <br /> 7. Transpoder 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address <br /> WORLD OIL RECYCLING U.S. EPA ID Number <br /> 2000 N . ALAMEDA STREET <br /> COMPTON CA 90222 <br /> Facilftys Phone: C 'A T 0 8 0. 0 '13 305 2 <br /> ga• 9b. U.S. DOT Description (including Proper Shipping Nat le, Hz zara Class, (D Number, 10. Containers <br /> HM and Packing Group (if any)) 11 . Total 12. Unit 13, Waste Codes <br /> No. Type Quantity Wt.I <br /> o 1 ' RQ. UN1993, WASTE FLAMMABLE LIQUID , N .O.S. , � /QQ <br /> (GASOLINE/DIESEL), 3.. PGII R <br /> s 2. QM G <br /> ! ' LU <br /> 3. <br /> 4, <br /> 14. Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT ; CHEMTREC 1- 0 4249300 WOES TERMINAL: CERES CS NAERG# 981 : 128 * PROFILE #-981 :. ' <br /> 440543 GASOLINE, DIESEL * * APPRO RI TE PPE EQUIPMENT .� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION l hereby d tare tat the contents of This consignment arean rate described above b the X000 <br /> . s <br /> Y p , P hipping name, and ere classified, packaged, <br /> marked and labeled/placarded, ancl are in all respects in pro r co ikon for transport according to applicable intemallonaland national governmental regulations. If ezportshipment acid I am the Primary <br /> Exporter, I certify that the contents of this consignment conrei e attached EPAAdmowledgntent of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 62.2T(a) Of I am a large quantity generator) or (b) (if l am a small uanlity generator) is Ime. <br /> Entomallo <br /> fs/0ife Pin yped Name Signature : Month Day Year <br /> —i ipmen s (� <br /> F t _I Import to U.S. ' ❑ Export from U.S. Pott of entrylexit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> 17. TransporterAcknowtedgmenl of Receipt of Materials ' <br /> III Trans r1 Prfnted/Typed Name Signature <br /> f / ^�. hfonth '.Day Year <br /> Q Transpoder 2 Printedfryped Name ;7 �-'•! <br /> Signature Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ ©uanlity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> uQ. FacilitysPhone: <br /> w 18c, Signature of Alternate Facility (or Generator) Month Day Year <br /> a " <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (f.c„ co s for tazardous waste treatment, disposal, and rocyding systems) <br /> W <br /> 1' 2. <br /> OMEN I <br /> 000000000 <br /> 20. Designated Facility Owner or Operator. Certification of receipt o ;, haza ous materials covered by the manifest except as noted in item 18a <br /> Printed/Typed Nante Signature 4Month Day Year <br /> EPA Form 8700-22 (Rev. 3 05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> I <br /> i <br />