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Please print or type.(Form designed for use on elite(12-pitch)typewriter.): Form Approved.OMB No.2050.0039 <br /> `l1NIFORM HAZARDOUS 1.Generator ID Number 2:P�2 e;of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESit C A t_0 0 0 3 3 0 4 2 3 ` i 1 (30014.24-9300 012411034 JJ K <br /> 5.Generalor's Name and Matting Address Generator's Site Address(if different than malting address) <br /> TRACY CHEVROLET-Q&M INC <br /> 3400 AUTO PLAZA WAY TRACY CA <br /> Genefator's Phone: 209 835 #'500 9 ECE-01=D <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ;,,, ,ASBURY EN V IR3 N MENTAL SERVICES FE6 ',� 7 CA D 020 2 7 7 0:3(r <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address I I AL HEALTH U.S.FPA ID Number <br /> DEt.ENNO/KERDOON DEPARTN4P7R <br /> 2000 N.ALAKDA STREET 1T <br /> COMPTON Cit 90222 CA d 090013352 <br /> Facility's Phone: C30153T-f�00 l <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(it any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> oc 1. UN12O3,WASTE GASOLINE.3.PG It D00i D0i8 343 <br /> o D 11i ---I-_.__I_.__. <br /> z 2 <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEFATREC i-1300-424-9300 NAER i*931:126 y PROFILE€r 93:Z:3"_G205 GACOLit_E <br /> POP A1.10184609*APPROPR ATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuralely 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 intematioh alai nd halional 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 allached EPAAcknowledgme of Consent. 11 <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b)(if I am a sma)quantity generator)is true. <br /> Generator'/Offeror' Pdnled7Typed Name Signature Month Day Year . <br /> �Z <br /> 16.International Shipments ' <br /> Z ❑Import to U.S. ElExport from U.S. Port of entry/ it: <br /> - Transporter signature(for exports only): Date leaving U.S.. <br /> w17.TransporterAcknowledgmenl of Receipt of Materials <br /> Transport Printed/Typed Naim _ ,� Signature �.�� Month Day Year <br /> za T ansp'orter 2Printed/Typed Name v ignature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanli e <br /> ty ElT Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V ' <br /> LL Facility's Phone: <br /> W 18c.Signature ofAllernate 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 /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br /> Print yped Name Signa ura-� Month Day Year <br /> EPA For 8700-22(Rev.3.05) Previous ed(iorisare obsolete. `f DESIGNA ED A(-ILITYTO GENERATOR STATE 6IF REQUIR D) <br />