Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 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 CAL000330423 :' ..r '"� 01405501.1. JJK <br /> 5 Generator's Name and_Mail' Address C1&AWI &l e t m dress) <br /> i RACY CHEVR ET-Q a M INC <br /> 3400 AUTO PLAZA WAY C, fi/ .•"• <br /> TRACY CA 953041 Q <br /> Generator's Phone: 2179 835-4500 J 2018 <br /> 6.Transporter 1 Commppa�ny Name U.S.EPA ID Number <br /> t•S[�1lFiY ENVIRONMENTAL SERVICES A I C A L)0 2 8'l. 7 7 u <br /> _ cr� e <br /> 7 Transporter 2 Company Name T� �1S,FFA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CEr:x.14t,'), i. 1�C ON <br /> 2000 N.AtAMEDA STREET <br /> COMPTON <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(•f any)) No, Type Quantity Wt.Nol. 13.Waste Codes <br /> 1• ',,N!' 9-1 WASTE FL4tAMABLE LIQUID. N O.S. (GASOLINE, DIESEL). 3. <br /> �- 0001 D016 34 <br /> of <br /> z 2. <br /> w <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> LMEl;iEf4C1 CC)PITF,GT : l i:i-mt I,FG 1-800-424-9300 NAERGO 981 :128 +PROFILE tK 981 :365974 GASOLINE. DIESEL * `° <br /> APPROPRIATE PERSONA? PROTECTIVE EQUIPMENT o' <br /> ��J/ /x � <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consenl. <br /> I certify Thal the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a,smail quantity generator)is true. <br /> Generator's/Offerors PrintedlTyped Narpe" Signature. Month Day Year <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> K Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> a _ _ <br /> U) <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> x- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp 1 1 <br /> ❑Type Residue El Re'ection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATE ILITY TO GENERATOR STATE(IF REQUIRED) <br />