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i 111111 Ilial I��ii�I�II VIII illll VIII Illi!VIII Il11 lNllll Ililil II IIl1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20540039 <br /> 1 Generator ID Number 2.Page i of 3.Emergent Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAD000633032 1 (8t�Re 321-8642 <br /> WASTE MANIFEST <br /> 5.G,WIo(4ESTan 1ddrRODUCTS LLC / MICHAEL PETE RS&eB 1Vtr trmCsJtentPRofte"It") LLC / MICHAEL PETE <br /> 2700 WEST WASHINGTON StREET 2700 WEST WASHINGTON StREET <br /> STOCKTON, CA 95203 STOCKTON CA 95203 <br /> (209)466-4407 GEN: 120604 SURVEY: 91099 <br /> Generators Phone: <br /> ransporter I Company Name U.S.EPA ID Number <br /> HERITAGE TRANSPORT, LLC—COOLIDGE IND058484114 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> s.D YhM"t0 NTAL SERV ICES LLC U.S.EPA ID Number <br /> 8525 NE 38TH STREET MOD981505555 <br /> KANSAS CITY MO 64161 <br /> Facility's Phone (b 16)453-4321 <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt[Vol. <br /> X 1 RQ UN1993 WASTE FLAMMABLE LIQUIDS N.O.S. , 4 DM 2580 P D00 D00 D008 <br /> 0 3 PGI1I, (GASbLINE/BENZENE), (DO09 D00� ), <br /> EhG#128, (4x559DM) D00 D010 34 <br /> Z 2. <br /> w <br /> C7 — <br /> 3. <br /> 4. <br /> 4.i pGcj HapyljnQl�Sj�u�tiQns an`!{d�litignfl'n12 , 13, 14 <br /> W �14y I t1 1 1124225016T <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accu.ately 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 inlernatior of and 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato 0 aro s ted/Typed yped Name , igna ure on ay ear <br /> S Q Q 8 <br /> —J 16.International Shipments <br /> ❑Import to U.S El Export from U.S. P of ntry/exit: <br /> Transporter signature for exports only). D eavin U S. <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printeday Year <br /> O <br /> CL <br /> QTransporter 2 nnted/Typed Name Signature nth ay ear <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone. <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> (n19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 H061 2 3 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> 3r,'AVIJ 'Ball . <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. D IGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> i 'AfJ <br />