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Please print or type. <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Aagit 1 of 3,Emergency Response Phone 4.Manifest Tracking Number <br /> WAS: MANIFEST CAROOO:+d21 JJ <br /> 5. n@rator's Name and Ma4ing Address 916371-17A7 <br /> Generators Site Address(if dlfferenf than mailing address) <br /> LOCI s STORAGE-wGAMPO t <br /> P.O- BOW 23D 2 3 N HM'9q <br /> AGAMPO, CA 96 0 ACAMPO,CA M <br /> Generators Pha <br /> 6.Transporter#Company Name <br /> U.S.EPA ID Number <br /> kWOS EWit"'t)NMENTAL SERVICES INC. rte- <br /> 7.Transporter 2 Cornpany Name <br /> t G� L �`� U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> PACIFIC RESOURCE RECC!'S1ERY <br /> fJ C t 'f U.S.EPA ID Number <br /> 3150 EAST PICO BLVD. ' <br /> LOS ANGELES,CA 9002,3 � C=AD!'3aE2524Q� <br /> Fal Phone: 499-7145 <br /> 9a. 9b,U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, f0.Containers <br /> HM and Packing Group(if any}} 11.Total 12.Unit <br /> No. Type Quantity Ill 13.Waste Codes <br /> 1' Ul WASTE PAiltiT,3,PGI;i <br /> 41— <br /> a 2. <br /> 1L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 9&1)PR011l0;lERx.126 <br /> E.F. CONTRACTOR: RAMOS E-NVIRONMENTAL 3 X= <br /> HANDLERS SH01iLD BF iFiAlf+lEa Aft}USE APPRO'+t;D PPE <br /> - <br /> R'S GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the # ' <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regu�ns.lff export shipment and are lI am the Packaged <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknpwledgment 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){ill am a small uanti enerator is true. <br /> Generators/Offerors PrnteIlTyped Name -- � ty9-- _ } <br /> Signature -. Month Day Year <br /> -j 16.Intema6ona15hipments --- 8 <br /> Import to U.S ❑Export from U.S. Port of <br /> entry/ext:Transporter signature{far exports only): <br /> W 17.TransporterAcknowledgment of Receipt of Materials Hate leaving U.S.: <br /> Transported Printffdl7yped Name <br /> r 1 <br /> Month Day Year <br /> Transporter 2 Prid_/ ped Na e <br /> j c Si Moat Day Year <br /> I <br /> 18.Discrepancy 40 1 <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Altemate Facility(or Generator) Manifest Reference Number: <br /> 'r U.S.EPA ID Number <br /> V <br /> LL 'Fal hone: <br /> LI <br /> 18c.Signatu Allemata Facility{or Generator) <br /> t— <br /> Z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> LU 1 2. 3. <br /> 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 <br /> Signature lAortth Day Year <br /> EPA f=orm 8700-22(Rev.V-17) Previous editions are obsolete. <br /> DE GNATED FACILITYTO GENERATOR <br />