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r �• <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 4 0 8 12-2 1 (800)424-9300 020381968 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> TIKI LAGUN MARINA RESORT- MCDONALD RD <br /> 12988 VY. MCDONALD ROAD <br /> STOCKTON CA 95206 <br /> Generator's Phone: 209 464-2980 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 'dVORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <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 /> WORLD OIL RECYCLING <br /> 2000 N.ALATkAEDA STREET <br /> CONIPTON CA 90222 CAT080013352 <br /> Facility's Phone: (310)53 7-7 100 <br /> 9a. 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 /> 1NON-RCRA HAEARDOUS WASTE, LIQUID(OILY WATER) 35 <br /> 0 I r� <br /> D M p V G <br /> z 2. <br /> L <br /> c9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT : CHEMTREC 1-800-424-9300 WOES TERMINAL: CERES CS NAERG#961 :171 *PROFILE#9r'1 <br /> 464373 OILY WATER * "APPROPRIATE PPE EQUIPMENT <br /> nJl 'µ (� r <br /> � if- *� <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the con ents 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 intemationaland 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 /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Generator's Offeror's Printed/Typed Name Signature Month Day Year <br /> 14 <br /> tee, 1-z,r © �b <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 /> LU <br /> Transporter 1 Printedffyped Name Signature / Month Day Year <br /> a ✓� i C�nD^t (n tn✓1 d, 5 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑TypeEl j j <br /> 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 /> L Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> U) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. , /7 2. 3. 4. <br /> 20.le ignated/Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name 1� c Signature Month <br /> 7 <br /> MonthDay 'Yeea�r <br /> A-0 <br /> V-0, <br /> r/� <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGN TED FACILITY TO EPA's e-MANIFEST SYSTEM <br />