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Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator Its Number2,Page t o 3 mergency ansa Phone 4.Mamfest Tracking Number <br /> WASTE MANIFEST C rI El# 31 <br /> 5.Generator's Name and Malin Address <br /> 9 Generator's Site Address(if different than mailing address) <br /> f.�Al..IFOR�IA )i�T F°;fas t r r il$N ssm r i^aVRC;C-A "f <br /> I571 T ;SA r <br /> Generatees Phone.'a-t �;µ a r= i t1 t i €.f h -r0At- <br /> Y.GA 953-76f! <br /> 6.Transporter 1 Company Name U.S.EPA ID Number District 11 <br /> MAER! AN VALLF--y ViiA3v OIL, a.; ' rlfs I <br /> ,": __ <br /> 7.Transporter 2 Company Noma U.S.EPA ID Number <br /> WORLDWIDE WIDEr R C OVER 1 Et INC, CFYR0001{§42� <br /> 8:DS{gnfiid Far Nttya7tt 5at1d'St <br /> .IMA YES 2 WASTE TRAMSr I X-%1 l a;' <br /> 5500 US!-JG1W3"A`Y`95 14 <br /> Facilty's Phone, <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nal. 13.Waste Codes <br /> 1. <br /> ON§ON-R(: A t-I, AR OL) ASST F5*LlCi,AS RBEN 6,0a I 3i#OC t <br /> 2. 1`K)�RC&I 0U,-a WAISTE SOLID,AB-S-D [EKf-S,0P- <br /> MA 400 362 <br /> 3. <br /> n <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> t. I2t :41 IB$ :i CIN A5SCIR IT;-,call_ E#J # 7 1'E d I r s 1 3 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described apgve by the proper shipping name,and are classified,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national god�etnmenlet 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 EPAAcknowledgmentoJ Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generatoq orr.6) i{am a smallA�anlity generator)is true, <br /> Generator s5Ql ffe�pr's Prinledfryped Name} Signa E Month Day Year <br /> ,j 16,Intematianat Shipments �—`� <br /> Import tod s. —17]Export from U.S. Port of entl?y xis <br /> Transporter signature(for exports only): Date leavi4U:'S,: <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Tri tl er 1 Pnntedffype S7172 <br /> g�tur Month Day Year <br /> �tri <br /> Z Transporter 21 nntadtrype(I Name Si natufe ""'" <br /> r g Month Ray �fYear <br /> • f � �r°� 2-0 3 <br /> I B.Discrepancy <br /> 18a.Discrepancy Indication Space {{��tt <br /> ❑ Quantity Type ❑Residue Partial Rejection �I Full Rejection <br /> JZ 18b.Alternate Facility for Generator) Manifest Reference Number. <br /> � U.S.EPA 1D Number <br /> U <br /> w 1 Be,Signature of Alternate Facility(or Generator) Month Day Year <br /> LDi <br /> 19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3 1_ 3 4. j <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in hem jAell :moi W <br /> Printed ype Name Signature1 Month Day Year <br /> EPA Form 70q-22(Rev:'I -1z Previous edit ns are obsolete." -'' - DESIGNATED FACILITYTO GENERATO <br />