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Please print or type. Form Approved OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pa e 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A z 0 0 0 0 a 3 3 41 � (sad) 424-9300 019333519 FLE <br /> i 5.Gene a Vs N me and Mailing Ad ress nerI's Addres di nt an me! address <br /> j Qu��C top Marts, Inc. V.fnrff�isi�,h��a, c. 4132 <br /> 165 Flanders Road Stnckton�95219 <br /> I Westborough, MR 01581 <br /> Generator's Phone. (510) 445-2202 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> BELSHIRE CAR0 0 01 A 3 913 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> i l <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number I <br /> World Oil Recycling CAT O S O O 13 3 b 2 <br /> 2000 N. AlaModa St. <br /> CoWton, CA 90222 (310) 537-7100 <br /> i Facility's Phone: l <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Noi. <br /> 1. VN1203, Gasoline Mixtureo 3, PG II 134 G 134 <br /> O X <br /> 001 <br /> W 2. <br /> jk <br /> 3. <br /> i <br /> i <br /> 4. i <br /> I <br /> 14 Sce lao 1-11%Instructions and Additional Information PZL BESI <br /> Gaoolins & water CLOrmm. � Q[TIXW" CIM: 659237 <br /> 15. GENERATOR'SIOFFEROR'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 international and 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 EPAAcknowledgment of Consent, <br /> I certify that the waste minimization statement Identified In 40 CFR 26227(a)(If I am a large quantity generator)or(b)(ifI am a small quantity generator)Is true, i <br /> Generator'slOfferor's Printed/Typed Name Signature Month Day Year ; <br /> - I <br /> 16.International Shipments ! <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ?1 Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/Typed Name _ Signature Month Day Year <br /> a (t� 27 lq <br /> CO) Transporter 2 Pr nted/Typed Name Signature Month. Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantit <br /> y El Type El Residue El Partial Rejection ❑Full Rejection <br /> i <br /> I <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number { <br /> _J I <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year i <br /> a lZ <br /> ti <br /> 9. azardou W Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. <br /> D signa F ciliV Ow per or erat :C$rtification of receipt of hazardous mate als vered manifest t as noted in 18a <br /> to yp d,Naf Signat c'. th a <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. TRANSPORTER COPY <br /> 132/3693562 I, <br />