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RECEIVED BY SJC EHD ON 7/23/2019 <br /> Please ptinf or type.(Form designed for use on elite(12-pitch)typewri(er.) Form Approved. OMB Na 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of3.Emergency Response Phone a.Manitest Tracking Number <br /> WASTE MANIFEST I CAL00030�22 } 371-5747 I 01-7154133 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Aderess(if different than mailing address) <br /> RAMOS OIL CO.•THORNTON �g <br /> PO BOX 401 ATTN: JOY KACHADORIAN R <br /> W Ti1ORNTON 0. <br /> THORNTON,CR 9N R <br /> WEST SACRAMENTO.CA 3!®1 I <br /> Generator's Pho t. . n <br /> 6.Transporter 1 Company Name U.S.EPA.ID Number <br /> RAMOS evittOm1>`JI(TAL sEmACEs INC. I CA0044ODM6 <br /> 1 Transporter 2 Company Name U S.EPA ID Number <br /> XV <br /> 3.Designated Facility Name and Site.Address U.S EPA ID Number <br /> PACIFIC RESOURCE RECOruERY 3150 ew CAS <br /> LOS �f.�A 111=1 <br /> Facility's Phone000'499.7145 1 <br /> ga 9b U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11 Total 12.Unit <br /> HM and Packing Group(if any)) 13 Waste Cafes <br /> No. Type Quantity Wt.tb'oi, <br /> Y 1 UN12D3,WASTE GASOLINE,3,PGH 001 DM so G 9' W01 DMa <br /> 0 <br /> a IZAL <br /> LUW 77LU <br /> 2. <br /> C9 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and.Additiortal Information <br /> E.R. COMRACMW RAIAM EWAtOWASITAL <br /> K I UM SHOO 111 W TRA/t W AND UN APPROVED PPE <br /> 15. GENEAATDR110OFFE11i CERTIFICATION: I hereby declare that the contents of this consignment aro illy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeleorpiacarded,and are in all respects in proper conditioe for transport according to applicable intemmonal and national governmental regulations.If export shipment and I am the Primary <br /> xporter,I certify that the ronten:s of this consignment conform to the lemis of the attached EPA ApnrovM V4M 4CMMI <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large r ardily ganwaks)01(01 em a_pmo quantity generator)is true. <br /> ilA1'Sr0�f9C6 f�NPY ypKltilamei Sgnatur . Month Day Year <br /> LZA' i iX,i Z 17 <br /> .J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexii: _ <br /> Transporter signature(for exports only): Date leaving U.S. <br /> u 17 TransporterAdmowledgmenl of Receipt of Materials <br /> nsopner 1 Printed'T,ped N Month Day Year <br /> QTrtnrlepaex'2 Pnntadlyped Napre J Si nature Month Day Year <br /> V,( <br /> T 18,Discrepancy OF <br /> 13a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partia'Rejection ❑Full Rejection. <br /> Manifest Reference Number: <br /> 18b.Afterrate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ca Facility's Phone: <br /> i8c.Sgrature of A.11eoate Facility(or Generator) I Month I Day Year <br /> d <br /> x <br /> a5 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 I2. I3. I4. <br /> POP, <br /> "I 1 <br /> ?0 Desgnatad Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest aTcept as noted in Item 18a <br /> Pnnted!Typed Name 'q Signal a Z Month Day Year <br /> ,-7 11? <br /> PA Form 8700-22(Rev X05) Previous editions are ohsolete. 4iEtit(-,NATE0 FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> t <br />