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<br />Form Approved. 01VIS No, 2050-0039
<br />EPA Form 8700-22 (Rev. 3-05) Previoun edibofts are Mulate- ut311ary„r ru rAWLr r r !LJ uco r rrenr rvn a inr & In r�ww.,. •�..!
<br />UNIFORM HAZARDOUS1. enerator ID, Number
<br />d 7
<br />2. Page 1 of
<br />1
<br />3, Emergency Response Phone
<br />4. Manifest Traoking Num er
<br />1007647404 FLE
<br />WASTtMANIFEST .Q
<br />{405f 3�i 3543
<br />5. Ganerabes Name and Willing Address t3enerator's Site Addrss's diffmrit than malling addresa)
<br />Love's Countr Stores of California Lroaa'a Country .a'tf rox of California[ #22;3
<br />F"O,'Box 8092 1553 W. Colon Road
<br />Rancho Septa Margarita, CA 92656 Ripcm, CA 95366.
<br />Ganardtefg Phone:
<br />E. 7ransponer Company ame , i
<br />U.S. EPA ID Number
<br />BELSHIRE V
<br />A0 0.0 1839 13
<br />9-Tfansporter 2Gompanv Nam® U,$. EPA ID Number
<br />8. Destgna Fadlity Nome and 5i+sAddress U,5, EPA ID Number
<br />Del4enao AKI rdoon GAT 0 6 0 0 13 3 5 2
<br />12COG N.Compton, 098251 ENVIRONMENTAL
<br />010) as7-7low- A'�rr_r r�rrD�QT9�t•rtT
<br />Fadltly's Plane:
<br />9a,
<br />9b. U.S. UOT Description (including Proper Shipping Name. Hazard Class, ID Number,
<br />10, Contatnere
<br />11. Total
<br />12. unit
<br />13- Waste Codes
<br />No,
<br />Type
<br />HM
<br />and Pacidrng Group (ii any))
<br />Quantity
<br />Wt.IWI.
<br />t, {.W1993, flammable Liquid, n"o_%, r 3, PC3III
<br />C,
<br />3$3
<br />o
<br />R
<br />(Contains Motor Fuel)
<br />Q 4 1
<br />Pi'r`
<br />010
<br />i
<br />2-
<br />w
<br />3,
<br />4.
<br />POLD 14, e andlIng Inytn coons and Additional IMortnalon WEAR ALL Ak?ROP�TE 8 E'i S I - 2 r5 3 3 6 2 UNE,J AAITIX Al
<br />�
<br />128 FROTECTIVFI CLOTHING 310@ OF KM
<br />Wst�er, Fuel, Qt -1, Brake Fluid, and httTimPIt11
<br />Hy+ix�cta a luifi TAB SMCXSOF
<br />utwu owrr r,jr
<br />15. GENERATORVOFFEROWS CERTIFICATION; I hereby dodare that the wMents of Sh15 consignment are fully and accurately described above by the proper shipping name, and are dassified, packaged,.
<br />marked and fabalodiplacarded,'and are In all res(aaecis In proper condition far transport sccorfrng to applicablo tntemadonat and national governmental regulations. If eXporl shlpment and I am the Primary
<br />E, pgtter, I certlty that the oordents of this consignment conform to ft terns o' the attached EPA Acknowledgment of Consent
<br />I oortify that ttra waste minlmlzatlon statement tderttlfied In 4D CFR 26127(s) (d I am a large quantity generator) or (bj (IP I am a small enaretoT) is two,
<br />GeneratoeslONerofsPrinleYrl ped Name Signature Month Day Year
<br />Larry Hoothart of 8ESI on behalf of generator OZ 1
<br />E-
<br />16. lnt¢matioalal Snlpm fills Import fa U.S. trY
<br />❑ ❑ r!w film U,B. Port of en lexis:
<br />Trams iters ri9ture Pe 1L5 on : Date IeaNn 11.8.;
<br />17. TtanspoferAcknowledgtnent of Receipt of MalarIEle
<br />1 PrintadfTyped Nerne Signatu Writhay year
<br />ran6pa63r
<br />zr
<br />2
<br />4
<br />Transportaz 2 Printbdfiyped Name momnear
<br />18, Discrepancy
<br />189, Otsaepancy Indoadon Space ❑ Ovate❑ Full Reyaddn
<br />❑ Type t. - E-1 Residua .J ❑ Partial RejP,cnon
<br />Manila t Referelce Number
<br />1 8b. Alternate Facility (or Gonerator) U.S. EPA ID Number
<br />r�
<br />,
<br />ka+-
<br />Fadli s PhotTe:
<br />3lgnatufe of Alternate Fadlhy (or Oenerstor) modth Day ear
<br />d
<br />a
<br />0
<br />t9, Hazarkus Waste Report Managentem Method Codee (I.e, codes for hazardous waste ttestmenf, disposal, and recycling systems)
<br />1.
<br />2. 3.
<br />4.
<br />20. Designated Facility Owner or Operator. Certification of ra0#t of hamMous materials covered by the mantfest except as noted In Item 18a
<br />Pdn ame Signature opt y Year
<br />.or nr nrnrnnrm
<br />EPA Form 8700-22 (Rev. 3-05) Previoun edibofts are Mulate- ut311ary„r ru rAWLr r r !LJ uco r rrenr rvn a inr & In r�ww.,. •�..!
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