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Please print or type. Form Approved.OMB No.2050-0039 <br /> T5. <br /> FORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number t <br /> ASTE MANIFEST CAL 0 0 0 4 2 7 0 0 4 (&X))424.93W 021524825 J J K <br /> nerator's Name and MailingAddress Generators Site Address(if different than mailing address) <br /> PARTY CITY#935 <br /> PO 80%2513 <br /> TRUCKEE CA 96160 2:359 W.KETTLEMAN LA14E <br /> rators Phone: 973 453.8600 L.ODI CA 95242 <br /> 6.Transporter 1 Company Name <br /> 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 /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> PACIFIC RESOURCE RECOVERY <br /> 3150 E.PICO BLVD <br /> LOS ANGELES CA 90023 C A D O 0 8 2 5 2 4 0 8 <br /> Facility's Phone: 1 5 <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 Typa Quanfity Wt.Nol. 13.Waste Codes <br /> 1. Non-RCRA HAZARDOUS WASTE.LIQUID(OIL) 221o ,. . <br /> Ll M G <br /> M 2. <br /> W <br /> t9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information I w f 17 77'0 17 7. i j <br /> EMERGENCY CONTACT:CHEMTREC 1.800.4249300 WOES TERMINAL:CERES CS NAERG#981:171*PROFILE 0 953:PC <br /> #935 OIL* -APPROPRIATE PPE EQUIPMENT <br /> F`1Lt. f��%� r.rtr <br /> 15. GENERATOR'SIOFFEROR'S 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 international 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 EPAAcknowledgment 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 /> Crera(o(hh'rg/e eroes Pn'n(d/TypeQ Npm 1` Signature ` Month Da Year <br /> ,dttl y! 1 Y Y <br /> J 16.International Shipments <br /> i.._ ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> Ix Transpd r 1 Printed/Typed Name Signature Mon Day Year <br /> IL t Ai <br /> Transporter 2 Printed/Typed Name Signature <br /> Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> _J <br /> V <br /> F aellry s phone: <br /> W 18c.Signature ofAltemate Fac lity(or Generator) Month Day Year <br /> Q <br /> 2 <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1' 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> yped Name Signature <br /> Month Day Year <br /> EPA Form 8700-21(Rev.12. 77) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />