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..: j - ..,. .__.. .. ..-...-._ .. .__......__ ._.___..-:..��..-,.....,.._-T--...^....P.......«.-...-ms........µ.... <br /> t <br /> 'ase prirtit or iype..'t,4, g. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phon701917.Manifest Tracking Number <br /> - 4075 WASTE MANIFEST :AI.Of C�3( ' .3 4� 916-3-711-5747 JJ <br /> 5.,Genera o ame and Mailing Address Generator's Site Address(if different than mailing address) <br /> 6364'. LII 0HERGH ST <br /> !=CKTON,CA 93206 <br /> Generator's Phone• 14-nq g <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RAIXIS ENVIRONIOEXiAL SERVICE-13 INC, ('AM-44 '39695 <br /> 7.Transporter 2 CompanyNameU.S./EPA ID Number <br /> A Fj�+ okj, ,..1. -�j e••s�.r`,p�.�.. <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> PACIFIC RESOURCE RECOVERY <br /> 3 16 EAST PICO BLVD. <br /> 1.08/41GELES,CA 9 J23 <br /> Facility's Phone: -4 -7146 `w <br /> ga. 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 WtNol. <br /> 1 t N1203,'v WASTE GASOLINE,3,P II �0 ! ( 331 DWII Dols <br /> O <br /> w <br /> w 2 UN13Z,1fL°ANTE FLrAI fv4A LE SOLID ORGANIC,IdI4 ,NOS,-4.1, PClil P 562 DMI ' E3Clfi"i <br /> (GASOLIN®,DEBRIS) <br /> 3. <br /> 14.Special Handling Instructions and Additional Information <br /> 98-1)PJROtFILE 'I71iCiWj ERG(`123 98- PROFILE 17/10173 ERC i33 <br /> 11ANDLERS SHOULD F rF,!kjIiIE- 3 oND LisE AppftovEij pP � •���� 5 <br /> 15. GENERATORWOFFEROWS 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 internallonaland 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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offeroes Pdntedgyped Name Signature Month Day Year <br /> k ; 14 6' =0r")G1�irl <br /> .`.1 16.International Shipments <br /> Import <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 /> LEsporter 1 P,inted[Typej Name ( SlgnatuK Month Day Year <br /> Z Transporter 2 PrintedtTyped Name �,r�, S n ure `! Month Day Year <br /> 18.Discrepancy d . <br /> 18a.Discrepancy Indication Space El Quantity O Type ❑Residue ❑Partial Rejection ❑Full RejecBon <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 1$c:Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 1 Ao- 2 1 3 4 <br /> FnntedsfiTypaed <br /> ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name Signature Month Day Year <br /> 10 4A /X/r( I <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. / "V, I NATED FACILIT`tTO t IENERA'OR <br />