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h , <br /> Pl or type, (Form designed for use on elite (12-pitch) typewriter.) r Form Approved, OMB No, 2050"0039 <br /> UNIFORM HAZARDOUS f • Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number Y <br /> WASTE MANIFEST CAL 0 0 0 3 5 3 7 5 3 ;� 1 (800) 424-9300 017467118168 JJ K <br /> 5. Generator's Name end ailing Address Generators Site Address (if different than mailing address) j <br /> VAN DE POL ENTERPRISE INC <br /> 351 NORTH BECKMAN ROAD <br /> LODi CQ ' ' 95240 a <br /> Generators Phone; 209 649-8308 a <br /> 6. Transporter 1 Company Name U,S, EPA ID Number <br /> WORLD 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 /> s 3 <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> DEMENNO / KERDOON <br /> 2000 N . ALAMEDA STREET <br /> COMPTON CA 90222 CAT 0 8 0 01. 3 3 5 2 t <br /> Facility$ Phone; 7 <br /> 98, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10, Containers 11 , Total 12, UniL <br /> fim and Packing Group (if any)) _ No, Type Quantity WtNol, 13. Waste Codes <br /> flown 1PC.lI SECj'� <br /> 9 1 'rrn�l . <br /> k <br /> ly <br /> tr <br /> YrY 1 Q LoLf f D M ss D001 331 <br /> A .0 G <br /> •S. <br /> 3, <br /> 14, Special Handling Instructions and Additional information <br /> EMERGENCY CONTACT , CHEMTREC 1-800.42¢9300 WOES TERMINALiP, CERES CS NAERG# 9B28 % PROFILE # 981 : <br /> 06082018.01 GASOLINE, DiESEL, 9132 : * APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 1 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurately described above by the propershipping 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 govemmentai 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 26227(a) (It I am a large quantity genera or (b) (ifi am a small quantity generator) Is true, <br /> Generators/Offerors Printed/Typed Name Sign r Month Day Year @ <br /> 'tea 6C 1103its <br /> ..r 16, Intemational Shipments <br /> i� ❑ import to U.S. ❑ Export from Port of anlryl ; <br /> Transporter signature (for exports only); Dale leaving U.S,; s <br /> 17. TransporterAckneededgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name hh Sign Month Day Year <br /> L A2s� IU OC 113 1 if <br /> ¢ Transporter 2Pdnted/rypedName Signature Month Day Year <br /> tom- <br /> 18. Discrepancy a <br /> 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue <br /> ❑ Partial Re)ecUon ❑ Full Rejection <br /> Manifest Reference Number, m <br /> 1111111F P 18b. Alternate Facility (or Generator) U.S. EFAID Number <br /> �r <br /> U <br /> LC Facility's Phone: <br /> w 18aSignature ofAlternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Loui, 2, 3. 40 <br /> 20tpesoatedFacflityOwfieror0parator. Cedificatlanofiewiptoth zardous ma als covered by the manifest except as noted In item 1 <br /> Pn edlTyp Name Signature Month. Day Year <br /> e <br /> EPA Form 8700.22 (Rev. 3 05) Previous editions are obsolete. DES AT.ED F CI 0 DESTINATION STATE (IF REOUIRED) <br />