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t�P A <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) r Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 al 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST A 1.U U 0 3 3 6 r; :' "t ] fjr '7) 1, 053427 JJK <br /> 5.Generator's Name and Mailing Address Geni'a, ',,�jJgf1dr nal"Ii a rens) <br /> 1fGtli:f +, ' '.f't_�t_11l IA INC 4 «6 <br /> 3400 AUTO PILVA WY Y <br /> ' - t:A 95304 MAR y � 2018 <br /> Generators Phone: S3�4F�0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FRYlGf97 "A EN L C <br /> 7.Transporter 2 Company Name ; i!k r ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> -i.i;.j Vi;.!{i."..t•.lir' <br /> v'r.N ALAMMASTRrET <br /> Fadlitys Phone: '♦ .i 100 <br /> ga, 9b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> 1' 11 1.'.:93,WASTF FLAMA%BLE LIQUID, N O.S..(GASOLINE. D4ESEL). <br /> NJ <br /> 2. <br /> w <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> i..fv'lEkl'Lki,;� R;-C 1.800.4249300NAERGM 961:128 *.PROFILF0981 : 98.874Gh"YOOVE. DIESEL �" y <br /> APPI171^�.Pt*T- n>'ZSQIlAI PROT¢Y"lYc <br /> c:; J "."�►' <br /> 15. GENERATOR'S10FFEROR'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 labelediplacarded,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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferoes Prinle"ped Name Signature Month Day Year <br /> 16.International Shipments <br /> 1:1 Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name / Signature Month Day Year <br /> a <br /> QTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type 1:1 Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> r,, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> wo 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 18a <br /> r <br /> tedrryped Name Signature Month Day Yeari <br /> EPA Form 8700-22(Rev.MS) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />