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an ..,. <br /> Ptepsr print or.tyQe:{Form designed f61'use,on writer:) a Form Approved.OMB No.2050- <br /> UNIFORM HAZAR69U,S t Generator ID Number 'Rage 1of P. <br /> Emergency Response Phone 4.ManHeat Tracking Number <br /> WASTE MANIFES �., JJ V <br /> 1 013081482 1(800)4244)300 <br /> n <br /> 5.Generator s Name and Mailing Address Genr?fators S to Address(if dKerent than mailing address) <br /> TRACY GHEVAOU -i� M INC <br /> TRACY UTS�iAA WAY <br /> CA'7M 2-2m4w <br /> 95304 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> MENTAL SERVICEs ICA <br /> 7.Transporter 2 Company Name � <br /> U.S.EPA ID Number <br /> 8.Desig�naateed*F�raccilliitty Name and Si�tye/Address U.S.% EPA ID Number <br /> (JO N.ALAM aA STREET <br /> 01D IFTON CI 90222 <br /> Facililys Phone: Ijj 0)532-7j 00 <br /> ;A p 2 <br /> ga. 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tote) 12.Unit <br /> }I� and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WL/vol' <br /> OO 1.ve <br /> A11120s,UWAS4FE GASOLINE, <br /> E,.3i,PG,,' ltiflp6 t1�9 A� <br /> r; LUD M <br /> W 2 )HIS WASTE S IREAM HAS BE <br /> tri <br /> FOR RECYCLING/TREATMENTS AT THE <br /> 3. r <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY l <br /> PERMITS TO RECEIVE YOUR'V STE STREAM AS <br /> 4. QUALIFIED.OUR EPA NUMBER 1S CATOW013352- <br /> VIRON Ei\ _ <br /> 14.SpecialHandling Instructions and Additional Infonnabon 9ART <br /> EMERGENCY CONTACT! GHEMTREC 1-000-424-9300 NANG#981 128*PROFILE#901:374.900 GASOLINE <br /> PO#A11019iS52 *APPROMIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GI?IERATDR SIDFFERDR'S CERTIFICATION:i hereby declare that the contents of this consignment are Mly and accu a descrabove by the per shipping name,and are classified,packaged, <br /> marked and Iabeledfplacarded,and are in all respects in proper condition for transport according to Applicable intemational and national governmental regulations.If export shipment and I arty the Primary <br /> Exporter,I cartly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minknaalloh statement Identified in 40 CFR 262.27(a)(if I am a large quantity ge small quantity generator)is true. <br /> Generators/Offerors PrintedfTyped Name 5 nature Month Day Y r� <br /> 16�International Shipments �c C <br /> F ❑Import to U.S. ❑Export from U.SF_.-'� P irlaf entry(g <br /> Transporter signature(for exports only: Date leaving U.S.:'— <br /> w17.Transporter Acknowledgment of Receipt of Materials <br /> t2 4.nsPdnt8d/Typed <br /> dnte&7yped Name Signature Month Day Year <br /> a IK <br /> co <br /> QN me nature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> i <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejerdicn ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> U. FacdWs Phone: <br /> 18c.Signature of Alternate Facility(or Generator), Month Day Year <br /> 10.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 2 Designated Facility Owner or Operator.Certification of receiptofpazardouws materials covered by the manifest except as rated In Ite ' a <br /> P <br /> ted/Typed Name �j f Signature Year <br /> EPA F 8700 22(Rev.3-05) Previous editions Yre obsolete. ( (GNATED FACILrtY O GF ERA A <br />