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09/21/2009 11:49 12093341873 FLAGCITV CHEVRON PAGE 10112 <br /> f FormAp oved.OMB No.2050-0039 <br /> Please print or type,(Form designed for usa on elite 12-pitch awrldr, <br /> UNIFORM HAZARDOUS 1 Eet r,�ator ID Numher 2,Page 1 of 3,Emergency Rnapanse Pt tme 4.NGintt((ea��t TrOekljngNumQb9r <br /> WASTE MANIFEST r �^ 1 209-61137-13857 01 f .�►'«1 � a5�+ ��� <br /> S,Generator";Name and Malting Address t'r K' U Generators SiteAddress(II different lien malhng adUres9) <br /> I`1-GAJ Sr C..���'lit"''p � <br /> Generator's Phone:.. •'y'3 9—0139 <br /> b. ensp c OIL Uom an NameVALLWASTU;3.EPA ID Number <br /> r���r�An WEY E: ��.�O�BS�ikB7'�3 <br /> U,S,EPA ID Number <br /> 7,Transporter z CampdnyName <br /> U.$,EPA ID Number <br /> H.S BA"Id a F' . <br /> 5300 CLAUS ROAi3 d'.A]GOa03,9Ut��.6 <br /> RWERBANK,CA9s36a <br /> FaONlty's Phone; <br /> 9e 9b.U.S.DoT Desorlptkm(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12,Unit 13.Waste eq <br /> 11M and Packing Group(if any)) No. Hf1e Quantity WlNol. <br /> 1. til € l$ �Lfl URU 221 <br /> °C . 0 1 . .� 43- <br /> 2.Uj <br /> i _.— <br /> c� � <br /> I <br /> 3. I <br /> 1d.5pecia111andlln�t0Vr—,,Sd Additional Information <br /> 15. GEN ERATOR'SjCFFEROR'S CERTIFICATION: I hereby drrlare that the contents Of tllls consignment are fully and aCCuratery described above by the proper shipping name,and are classigsd,packaged, <br /> marked and Iaboledlplararded,and are In all respects in proper condition for transport according to 3ppllrable intornatlonal and national govemmenhll regulations.If export shipment and I am the Primary <br /> Exporter,I cortlfy that the contents of this consignment conform to the terms of the attachsd CPAAcknowladpment of Consent, <br /> 1 certify that the waste minlmhatlon statement Identified in 40 CFR 262,27(a)(If I am a large quantity(jortentor)or(b)(If I am a small quanllry generator)Is true. <br /> igna ro �rnih y ear <br /> Generstor'slUtlerore dntedlType0 Name c -- � <br /> ` <br /> ,j 116.International Shipments' Import to U.S, ❑Export from U.S. Port of entryloxit, — -- <br /> 5- Trots Tier sl rstura for export-9 on : Data leaving U.S.: <br /> IX 17.Trsnspofter Acknowledgmoilf of Receipt of M3Ionals Month ay Year <br /> Transporter 1 PrintedlTyped Name gnaluro �/ <br /> a Transporter 2 PdntedlTypeo Name 5 attire <br /> Mon 1 Day Year <br /> r <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Spaco ❑Type Residue ❑Partial Rejection ❑FuII Rejoctlorl <br /> ❑ <br /> Manliest Rafer6nco Number. <br /> U.S.EPA ID Number <br /> lob.Altornare Facility(or Generator) <br /> U <br /> W <br /> Facility's Phone' Month Day Yoar <br /> 18c.Signature of Altswato Facility(or Generator) <br /> a <br /> z <br /> 19.Haz3r[Icws Waste Report Manogomont Method Codes(1.e.,codes for h37Ardous waste treatment disposal,and recycling systems} <br /> 3. 4, <br /> 41 <br /> 20.Designated Facility Owner or Operator:CerUficotlon of receipt of hazardous materials covered by the manlfe9t except as holed In Item 193 Ma tr, Day Year <br /> Printt�drTyped Name, / <br /> �OrV7 <br /> /r <br /> EPA Form 8700.22(Rev, 5) Previous editions are obsolato. �` �-' �/r DESIGNATED FACILITY TO GENERATOR <br />