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A or type.(Form des' ned for use on elite(12-pitch)typewriter. Form Approved.OMB No,2050-0039 <br /> 1.Generator ID Number 2.Page 1 d Ems cy Response Phone 4.M nifest Trackin Nu <br /> AIF�RM MtAZARnous +��.��,� �9 4 JJ K <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different mailing address) <br /> Mountain Valley Express 1019 Ressenier Drive <br /> PO Box 2559 Manteca,CA 9533e. <br /> Manteca,CA 95338 <br /> Generator's Phone: r <br /> 6.Transporter 1 Company Nara_23 as U.S.EPA ID Numb <br /> Fretnotrwr Environments!Services.Inc. CAROW171017 <br /> 7,Transporter 2 Company Nara U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Num <br /> DK Dixon CATeaM121302 <br /> 7300 Chevron Way <br /> Dixon,CA 9W20Facili 13$ <br /> 's Phone: 707-693-30 <br /> ger 1 9b.U.S.DOT Description(inducting Proper Shipping Name,HazardClass,ID Number, <br /> 10.Containers ii.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(d airy)) No. Type Quantity WtNd. <br /> 1• Ivor!RCRA Hazardous Waste,Liquid,(Oily Water) � G 223 <br /> Z 2. <br /> LU <br /> 3. <br /> ' to _ <br /> D K Dixon has e <br /> i <br /> 4. <br /> New your I <br /> wao.Our EPA 1 Num is CAT Q12 <br /> _ 14.Special Handling Instructions and Additional Information -7 <br /> tib 1)Oily Watm-ERG 171 ; � •3 <br /> 05 <br /> ProftleC Qtca2n1a7 <br /> Mandlem to be 40HR Trained rm!dear Proper PPE <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper sldpplrgi name,and are dau fed,packaged, <br /> marked and labelekyplacarded,and are in all respects in proper cwAftn for transport according to applicable Indenallorml and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certilly that the contends of this consignment conform to the terms of the attacAned EPA ent of Consent. <br /> I certify that the waste minimdatio r staff ider0d in 40 CFR 262.27(a)(if I am a large quantity gerrmator)or(b)(f I an a small quantity generator)is true. <br /> GeneratoftWerces PrintedlTyped Name SkJnalure Month Day Year <br /> r `.. ., 'f ;, fir.✓ c j <br /> F 16.International Shipments <br /> F- ❑Import t4 U.S. ❑Export from U.S. Pont of entryfadt <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Admowledgment of Receipt of Mads <br /> Year <br /> W Transporter 1 Prin MIT Name Signature Y-11 12 <br /> QTrensporlar2 Prtrntedfryped Name Signature Month 0ay Year <br /> tr <br /> H <br /> 18.Discrepancy 4 <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Res" cf F Rejerdion <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA I era - <br /> 0 FaclfifsPtrone: Month Day Year <br /> w 18c.Signature ofAlfemate Facility(o Generator} <br /> Q <br /> S2 19.Hazardous Waste Report Management Method Codes(La.,oodes for hazardous waste treatment,disposal,and recycling systems) <br /> j 1 A., 1 L U 2. 3. 4. <br /> 20.Designated Facility Owner or Rperator Certification of receipt of haz"qds materials covered by the manifest except as noted in Item 18a 1 <br /> Print y e..--2 (�' .. Signature f,. '. --- Month Day <br /> Year <br /> EPA Form 8700-22(Rev.3-05) Previou editions are obs ofe �'r DESIGNATED FACILITY TO GENERATOR <br />