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Please ptoi or type, Form Approved.OMB No,205a023 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3,Emergency Reslponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST A L 0 0 0 4 0 "i 0 3 0 1 8001424-9300 0 2 6 9 0 4 9 4 3 JA <br /> 5,Generator's Name and Mailing Address Generators SlleAddress lif clerert than mailing address) <br /> UNIT7D#5447 <br /> 1301 ACADEMY CT <br /> rl COLLINS RL' 00 14W C RwMth L <br /> Generator's Phone: 916 991.1100 STOCKTON CA 9521"J <br /> 6.Twspoder 1 Company Name US,EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 03 6 <br /> 7,Tmnsporfer2 Company Name U,S.EPA ID Num�r <br /> 8,Designated Fadlity Name and Site Address U,S,EPA 10 Number <br /> PACIFIC RESOURCE RECOVERY <br /> 3150 E. PICO BLVD, <br /> LOSANGELES CA 90023 CAD008252405 <br /> Faciliys Phase, (80OA99 7145 <br /> ga 9b,US.007Des OOPprdudirQPmp fShlppiopName,Hma Cll IDNuft,, 10 Co ielnem 11 Total 12 Unit <br /> HM and Padflog Group(6an# No, Type Quarltty WI,No(, 13,Waste Codes <br /> 101325,WASTE FLAMMABLE SOLIDS,ORGANIC. N.O.S., (FUEL <br /> D001 D018 52 <br /> o <br /> 0 HOSES, PUMPS, DEBRIS). 4.1, PGII I P <br /> w <br /> z <br /> w <br /> 3. <br /> 4. <br /> 14,Spedal Handling Inshctlons and Additional Infomrator <br /> EMERGENCY CONTACT CHEMTREC 1-8Z4249300 WOES TERMINAL: CERES CS NAEPG#9B1 :133 PRORLE#981 �38�z1 <br /> UN11002-30725 FUEL HOSES, PUMPS DEBRIS *P500-00139593 *APPROPRIATE PPE EQUIPMENT U <br /> 15 GENERATORTOFFEROR'S CERTIFICATION: I hereby dedare chat de rcentenfs of this consignment are fully and accuumtely descdbecl above by the proper shippee name,and are classted,packaged, <br /> marked and labelediplacarded,and are in all respects In propercenditon for tanspod according to applioable inlematonaland natonal governmental regulatons If export shipment and lam the Primary <br /> Expu�er,I cedty that t^e c;,nfenfs cf dis consignment conform fe tre terms cf tre artarh2d EPAAcknavrledgmen•:of Consent <br /> 1-0 lhaf the waste minimiralion statement identfied in 40 OR 282.27laj It I am a large quani generafor)or(b)Ilfl am a small quantity generalorj U hue. <br /> Gener . sl0tiemrs Pdnted7*Na Signature ntl Day Yea; <br /> ?6.IrileknalShipmers 0 m odicU.S.p Expod tom U.S Pon of ent i6l, <br /> ? Transpodersipnaturelforexpohsonlyj: Dale leavinp J.S <br /> W ?7.TranspaderAcknowtedgmentofReceiptofWedals <br /> Tra spud i Pdrted7 erne Signature Mont! D^ Year <br /> z anspprl12 Pdrled!Typed Name Signalure Month Day Year <br /> Q <br /> 8.Discrepancy <br /> 18a Discepancy Irdiaton Space Quo OType Residue Partial Rejecfion Full Rejector <br /> Manifest Reference Number <br /> F I8b,Alemale Fadlify for Generator] U S.EPA ID Number <br /> J <br /> U <br /> LL Facillys Phone: <br /> w 18c.Slgratre ofAllemate Facility for Generator) Month Day Year <br /> Q <br /> z <br /> N10.Hazardous Waste Repod Managemenl Melhod Codes Il e,cedes for hazardous waste teatment,disposal,and recycling syslems) <br /> G 1 2. 3, 4. <br /> 20.Designafed Facil4 Owner or Op color.CerfMcaton of receipt of hazardous maledals covered by the m@Nfesl except as nded in Item 18a <br /> PrnledlT Name Signature Month Day Year <br /> UAL �11 ( � �e 3 z �� <br /> EPA Form8700d21Rev.12.171PreviouseditionsFeobsolete, DESIGNATED fACILITYTOEPA'se-MANIFEST SYSTEM <br />