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RECEIVED 02/05/2022 <br /> Please print or type. Form Approved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTnaftlill 1006830180 G B F <br /> 5.Generator's Name and Mailing Address Generators Site Address(if drfferent than mailing address) <br /> Valley Pacilfe Petroleum-Lodi 930 E Victor Rd <br /> 152 Frank West Cir Ste 100 <br /> 209-800-2983 <br /> Stockton.CA 95208 Lodl,CA 85240 <br /> Generators Phone: <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> Independence Environmental Services LLC CAR000306548 <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> B.Designated Facility Name and Site Address U.S-EPA ID Number <br /> EmAronmental Waste Solutions <br /> 31915 Industrial Ln AZR000520478 <br /> 877-227-0189 Parker South,AZ 85344 <br /> Facility's Phone: <br /> 9a 9b.U S,DOT Description(including Proper Shipping Name,Hazard Class.ID Number. 10 Containers 11 Tota! 12.Unit <br /> HM and Packing Group(if any)} 13.Waste Codes <br /> No. Type Quantity Wt.NoL <br /> 1. <br /> p Non RC RA Hazardous Waste,Liquid(Oily Water) 001 TI z50� G 27-3 <br /> a <br /> rr <br /> w <br /> z 2 <br /> LU <br /> [7 <br /> 4 <br /> 14.Special handling Instructions and Additional Info tion <br /> ERG#171 �� <br /> Eft Contract#MIS9933011 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shtpping name.and are classified,packaged, <br /> marked and labeledlplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental reguiations.H export shipment and I am the Prmary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 lb)(ii I an a small quantity ge eraloO is we. <br /> Genera Offerors PrintedlT Name Signature Month Day Year <br /> C At Z { <br /> � 16,international ipments <br /> ❑Import to U.S. ❑Export from U.S. ort of entrytexif <br /> Transporter signature(for exports only), Date leaving U.S.: <br /> W 17 Transporter Acknowledgment of Receipt of Matenals <br /> It- Trans ler 1 Prnted7yped Name Si nature Month Day Year <br /> ZTransporter 2 Priptecl,Typed Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity 1-1 Type ❑Residue ❑Partial Rejection LJ Full Rejection <br /> Manifest Relerence Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> < Facility$Phone <br /> Lo 18c-Signature of Alternate Facility(or Generator) Month Day Year <br /> u <br /> Q <br /> 2 <br /> 19.Hazardous Waste port Management Method Codes(i e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20. es!gnated Faality Owner or Oper for Certification of receipt of hazardous materials covered by the manife cept as noted in Hin 18a <br /> Pn e +Typed Name Signet Month Day Year <br /> EPA Farm 8700-22 tRev.12-17) Prev us editions are obsolete. DEGMAT Fi,CiLCTY TO EPA's e-Nf,4NIFEST SYST <br />