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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.G er t r ID N m 2.Page 1 of 3.Emergency Response Phone-r021323914 <br /> .Manifest Tracking Number <br /> z8 16-371-5747 0 213 2 3 914 JJ K <br /> WASTE MANIFEST $sig <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> VAN BUSKIRK GOLF COURSE <br /> 1740 HOUSTONE AVE <br /> STOCKTON,CA 95206 <br /> Generators PhonROS�610-3726 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RAMOS ENVIRONMENTAL SERVICES INC. CA0044003556 <br /> 7.Transporter 2 Company Name : U.S.EPA ID Number <br /> S <br /> 8.Designated Facility Name and SiteAddre"PACIFIC RESOURCE RECOVERY U.S.EPA ID Number <br /> 3150 EAST PICO BLVD. CA0008252405 <br /> LOS ANGELES,CA 90023 <br /> Facility's PhoneOO-499-7145 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 VYas�Codes <br /> HM and Packing Group(If any)) No. Type Quantity WtNol. <br /> 1. UN1203,WASTE GASOLINE,3,PGII G 331 MM D018 <br /> 2 <br /> 6-0 <br /> Z 20 <br /> W <br /> 4. <br /> 14.Special Handing Instructions and Additional Information <br /> 981)PROFILE# ERG#128 <br /> HANDLERS TO BE TRAINED AND USE APPROVED PPE. �-- <br /> E.R. CONTRACTOR: RAMOS ENVIRONMENTAL SERVICES x <br /> 15. GENERATOR'S/OFFEROR'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 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 EPA Acknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity g rator)or(b)(dl 4a small quantity generator)is true. <br /> Zeroes Prinled/Typed N me gn lure Monti Day Year <br /> t� r( Z leg I 7A <br /> 16.ntemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. ort of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 Printed/Typed Nam Signature Month Day Year <br /> aQ2 7�8 Z� <br /> Z Transporter 2 PrintedlTyped Name /l Signature Month Day Year <br /> o.? or2 a <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity 1:1 Type El Residue Partial Rejection an Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> QW 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> 2 <br /> W 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> A <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncte4jqi Item 18a <br /> Nnted/Typed Name Signature tlf <br /> EPA Form 8700 22(Rev.12-1 TT Pre ous edit ons are obsole ESIGNATED FACILITY TO EPA'S O-MANIFES 'SY TEM <br />