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Please print or typo. Form Approved_OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST C'�,LG:,"U4AX 7 :2x 22EIY35 1026530306 JJK <br /> S.Generator's Name and Meiling Address Generator's Site Address(if differed than melling address) <br /> 1 API IA PETROLEUM CORP. <br /> 376 E MAIN St <br /> tRPONY CA SKID% <br /> Generator's Phone: <br /> 8,iransporter 1 Company Name U.S.EPA ID Number <br /> Gaeprnu VV.Lowy,)M, <br /> `?VOC M47C19 <br /> T.Transporter 2 Company flame U.S.EPA ID Number <br /> 8.Deslgg�nata1d• a, ity NameUlLgand <br /> rSlite Address U.S.EPA iD Number <br /> = ern on ,-.�_:•,.: ;r.'_i1c <br /> FadifVs Phone:X2,8B,81 1 <br /> go, 9b.U.S.00T Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Contalnera 11.Toter 12.Unit 13.Waste Codas <br /> HM and Packing Group(If any)) No. Type Quantity MJVoL <br /> lY X 1 :aC4l rY:t?? ri ZADLrS' "}A ST=t ' [fir: f r 1 i J. ma's <br /> _.1 1 <br /> 0 vsn pxt.) <br /> �+ 2. � t <br /> 3. ; <br /> f <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ER..v i;It 3 <br /> 15. GENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shppirV name,arri are classified,packaged, <br /> marked and tsbeledfplacarded,and are in all-respects in propercondhlon for transport according to applicable intematonaland national governmental regulations.Hexport sKonent and I am the Primary <br /> Exporter,I certify that the contorts of this consignment conform to the terms of fhe attached EPAAckno vlectrent of Conset <br /> i witty that the waste minimization statement identified in 40 CFR 26227(a)(if t am a large quantity generator)or(b)Cd l am a small quantity generator)is true. <br /> Gonerator'slOHer s Printed/ryped Narne Signature 7 Month Day Year <br /> c <br /> 16.intemationa Shipdrents ❑ E tG <br /> import to U.S. ❑Export from U.S. Port of entryiexit: <br /> Transporter signature(for exports ortty): Date Ieavtirg U.S.: <br /> ix w 'i .Transixxter Acknowlecigment of Receot of Materials <br /> {p� Transporter 1 PrintedrTyd Name r S gnafu e WbnL1 Day Y� <br /> AZZ <br /> j! Transporter 2 Printed!Typed Name S gnatura Month Day ear <br /> i-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quentity Type C Residue ❑Partial Rejection U FUA Rej�lion <br /> Manifest Reference Number <br /> 18b.Alternate Factity(or venerator) U.S.EPA ID Number <br /> v <br /> uQ. Factty's Phone: <br /> 8c,Signature of Altemate Fadlity(or Generator) Month Day Year <br /> r— <br /> l 19.Hazardous Waste Report snaemment Method Codes(i.e.,codes for hazardous waste ireabrwnt disposal•and recycling systems) <br /> 3, 4. <br /> 20.Designated F ly wner or Operator:Ceriftation of re of t of hazadow materials.00vered by the manifest except as nowttem <br /> Printedffyped Name < Slgreture Mirth ay Year <br /> /11f 17 /Z4, <br /> EPA Form 870D-22(R .12-17) Previous edition are obsolete. E3c5lrsNA D FACILITY TO EMS t3-MANIFEST SYSTEM <br /> i <br /> i <br /> "I � <br />