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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 12.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number yy 1�( <br /> WASTE MANIFEST N 3 it",",' {7 .L ; JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone;� . <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> -f'.Ao <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and'SiteAddress `" U.S.EPA ID Number <br /> F'P.CIFIC RESOURCE RECOVERY <br /> 7+160 EASIT PICO BUJI). <br /> t-v ANGELES,CA ",255; <br /> Facility's Phone:, :LI- ++�' <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' UN1203,'WASTE GASOLIW,3,P•GO ,, <br /> /®O <br /> W <br /> z .. 2. <br /> W _ <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 71 <br /> EA, COI:{rMACTOR IACIS ENV111RUNMEfiTAL. <br /> H-Af DL.ERS SHOULD BE TRAINED 440 USE APPRVI'ED PPE- <br /> 15. <br /> PE15. 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 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/Qfferoes Prin d/TypI Name Signature t' Month Day Year <br /> 16.International Shipments <br /> I.- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ll'- Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a / � <br /> QTransporter 2 Pdnted/Typed Name Signature Y,' Month Day Year <br /> f <br /> Z' ti <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑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 /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Zz11 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 0i t <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/TypedName -fLSignature Month Day Year <br /> ` t"-,I I l i I� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />