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Please print or type. Form Approved.OMB No.2050-0039 <br /> t UNIFORM HAZARDOUS 1.Generator ID Number 2. -'ge 1 Of 3.Emergency Response Phone 4.Manifest Track' Number <br /> WASTE MANIFEST Cir A L 0 0 0 '� � � � " 5 1925) 701-����. � 01.5 X81454 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Addfess(if different than mailing address) <br /> North Pole Gas 6 Food Inc. Pole Gas Station <br /> 574 19. Grantline Rd. 57 MGat Gran Line lid <br /> Tracy, CA 953'76 �- Tracy, CA .9576 <br /> Generators Phone: (923) 701-1111 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> BELSHIRE CA3 0 0 0 18 3 813 <br /> 7.Transporter 2 Co pany Name U.S.EPA ID Number <br /> �; P. l �� cit; "ti,rr ,� . - i A 1 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> World Oil Recycling _. CAT 0 80 013 352 <br /> 2.Q00 N. Alana St-. <br /> Compton, (CA 90222 (310) 537-7100 <br /> Facility's Phone: !. . <br /> 9b.U.S.DOT Description(including ProperShi m Name,Hazard Class,ID Number, 10.Containers <br /> 9a. P• (• gShipping .- 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NOI. <br /> o x 1. UN1203, Gatl;f 14ne Mixture, 3, PQ II G 134 <br /> W <br /> W 2.. fj i <br /> C9 Y <br /> 3. . <br /> 4• <br /> 14.Special Handling Instructions and Additional Information ,Jflm A� PPWRIATE g�, Z : C <br /> "01tBING . J <br /> Gasoline Matter <br /> '3-Y.5S <br /> 15. GENERATOR'SIOFFEROR%CERTIFICATION: I hereby declare that the conter)ts of this cons'' n nt are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplecarded,and are in all respects in proper condition for Uangport accordmg to p W,,ble intemationaland national governmental regulations.If export shipment and Pam the Primary <br /> Exporter,I certify that the contents of this consignment conform tO the terms of the aflachad EPAAe edgment of Consent. <br /> cefity that the waste minimization statement identified in 40 SLR 262.27(a)(if I am a large quarHnerator)ot(b)(if[am a small quantity generor)is;lrue. <br /> (lenerator$/O�fe Or'VPVrinteqrryped Name r r rgnature Month Day Year <br /> 4zlk <br /> .�j 16.Intern4tieo <br /> �naI Ship nl <br /> j..,, ls <br /> -- �I npo to U.S. �`'❑Expo_ t)S.: Pori of enl /exd - <br /> Z Transporter signalar (rekports only): Date leavi g U,S.. <br /> C 17.Transporter Ayknowledgment of Receipt of Materials <br /> LU <br /> FQ, Transporter 1 Printed/TiEed Name [ f ignature Month Day Year <br /> Z- Transporter 2 Printedrriyped Name nature" <br /> Y, j' Month Day Year f <br /> - - <br /> „. <br /> 18.Discrepancy - -- <br /> 18a.Discrepancy Indication Space ` / <br /> ❑ Quantity ❑Type.`', ❑-ftesfdue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 186.Alternate Facility(or Generator) r, U.S.EPA ID Number <br /> V � <br /> LL Facility's Phone: <br /> W 18c.Signaturg of Alternate Facility(or Generator) Month Day Year <br /> Z , <br /> U) 19.Hazardous Waste Report Management Method Codes(i e.;codes for hazardous waste treatment,disposl,and recycling systems) ! <br /> 0 1. t 2. 3 4 <br /> 20.Designated Facility Owner or Operator:Certification of-receipt of hazardous materials covered by the mapifesl except as nded in Item 18a <br /> Printed/Typed Name Signature, ` . i- Month!(( Day Year <br /> 16 l i zz.- <br /> EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. TRANSPORTER COPY <br />