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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generale ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST I CApXMQ149 1 31X371574701. 9175905 JJK <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> LODI GAS S T ORAiGE-ACAMPO 232M W Wvff 99 MCI�F <br /> P.O. F5Ox 230 ACAMPO, CA %220 <br /> ACAMPO.CA 955220 <br /> Generators Phon ''� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RAMOS ENVIR-ONME:ItiI AL SERVICES INC. CAQCr4417'3 <br /> 7.Transporter 2 Company Name P 1 !1< )ri U,S.EPA ID Number <br /> S.Designated Facifity Name and Site Address 1 U [Lr U.S.EPA ID Number <br /> RAMOS EI'e�71YC51`dMENTAL SERMCES Imc <br /> 1515'1UrH RIVEki RD. ------- _ .- CA„X34d� <br /> WEST`SACRMME NTO,CA 95691 <br /> ------ <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> Na. Type Quantity Wt.Nol. <br /> 1, NON RCRA HAZARDOUS WASTE SOLID (Oil_, wwiS) <br /> O P 351 <br /> 6'o , <br /> f <br /> a <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Et9-11)PROF'ILE# 1892 ..•- 71 <br /> ER CONTRACTOR: RAMOS EPNVJROf+i S X <br /> HANDLERS SHOULD RE TRAWED AND USE APPRO',4E-3 ppe Sou 17 C Z,O <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dec#are that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland 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 /> GeneratorslOfferors Printed Typed Name Signature <br /> _ Month Day Year <br /> „1 16.International Shipments --- <br /> F- ❑Import to U. ❑Export from�.5:1 - -� Port of entry/exit: <br /> ? Transporter signature(far exports only)! Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> �C Transporter 1 PrintedfTyped Name / S,g-=—tL e~ Month Day Year <br /> a <br /> Z Transporter 2 Printeov I ypel Name Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity 1:1 Type EJ Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference N' er: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U I <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. <br /> 13. <br /> P 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 /> PrinledlTyped Name Signature Month Day Year <br /> .r -� e <br /> EPA Form 8700-22 f ev.12-17) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />