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Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1,Genorator ID Number 2.Page 1 of 3.Emergency Response Phone <br /> WASTE MANIFEST . CAR000220046 7 1 909-984-9984 1"T'172"1193 <br /> FLE <br /> 8.Generator'B Name and Mailing Address Generator's Site Address(if different than malling address) <br /> CALIFORNIA, HEALTH CARE FACILITY (07557) 7707 SOUTH =TIN ROAD <br /> 7707 SOUTH AVSTXN ROAD (attn: M. whistle STOCKTON, CA 95215 (attn:mark whistler) } i <br /> tSTOCKTON, CA 9521.5 <br /> Generalars Phone; <br /> 8.Transporter 1 Company Nem@ U.S.EPA ID Number <br /> ITTTL;ZATION, INC. <br /> 7.Transporter 2 Company Name U.S.EPAID Number + <br /> 8,Designated Facility Name and Site Address U.S.EPAID Number <br /> WORLID OIL RECYCLING <br /> 22p0000s. N. A'LAWDA STREET <br /> FaclGty`s PION 7 C3� 90222 <br /> rf, 9b.U.S.DCT Description(including Proper Stopping Name,Hazard Class,ID Number, 10.Containers 19.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No, i,rpB Quantity WtNol, <br /> g� 1'Vm RCRA Hazardous waste li,cNi-d (wastrs oil) 221 <br /> 2. <br /> t� <br /> 3. <br /> 4. <br /> 14.Spec al Handling Instructions and Additional Infannation <br /> 1) motor oil/app:68910 <br /> 15. GENERATO11181OFFEROR'S CERTIFICATION:I herebydeciare that the contents of this wnBignmentare fullyand accurately described above by the propershipping name,and are classIlied,packaged, <br /> marked and labeledlplaearded,and are In all respects In proper condition for transpod according to applicable krIemationaiand national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of thfs censlgrmontconformto the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste mlnlmizaticn statement Identified In 40 CFR 202.27(a)(if I am a large quantIly generator)or )(A am a small querill"aneraler)is true. <br /> Genaror's PrinWfTyped Name Signature „�►- Month ay Year <br /> —j B.Inlemadona €pm is / <br /> � ❑EMport J.S.to Export from U.S. port of entryleft <br /> M Transportersignature(for exports only): Date leaft U.S.; <br /> IX 17.TransporterAcknowledgmentofReceipt ofMaterials <br /> Transporter 1 Printedfryped araeSlgnatum L Month Day Year gr <br /> nedAo w <br /> a <br /> Z Tr rter2Pdntedliype me Signature Man Day ear <br /> 19.D)screpancy <br /> 18a.Discrepancy Indication Space 1-1 puanfity ❑Type ❑Resldue ❑Partial R@Jectiea ❑Fug Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facdily's Phone: <br /> W 18c,Signature ofAltemateFacility(or Generator) Month Day Year <br /> z <br /> I <br /> dous Report Management Method Codes(I.e.,codes for hazardous waste Uestrnant,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 11 1 <br /> ate Facity wnororOp ra :CertiBcatio f recelptof hazardous a rialscovet bythemanifest a pt s noted In li a& natu _ b <br /> r MCI <br /> Form 8700.22(Rev12 <br /> . -17) Previous editions are obsoie s. L)V51UNAThU PAGILITY TO EPA's e�MANIFEST SYSTEM <br />