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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Cenera:or 10 Number 2,Pape I of 3,Emergency Response Phone 0.Man'rfxl Trapkirg Number <br /> WASTE MANIFEST :ALof0=75332 t 909-'21-2u2le 0 0 7 0 7 9 7 JJK <br /> 5,Generators Name and Maikng Address Genemtars site Address to different than mailing address) <br /> CIPCLE K STORE3&1!CHELLE V:'ILSOPI <br /> 495 E RINCON,STE 150 CI RCLE K#2701205. 104 7O CAh53RI CG <br /> CORONA. CA 92879 LATNROP CA 95330 <br /> Generators PhI 209-858-41113 <br /> S.Transporter 1 Company Name U.S.EPA 10 Number <br /> ENVtRONNIENITAL LOGISTICS, !NC CAR000172 n�6 <br /> 7.Transporter 2 Canpam,Name U.S.EPA ID Number <br /> s.OaI� i�rr;CES INC U.S.EPAID Number <br /> 1BOW. IAONITE AVE CA0982444481 <br /> RIALTO CA 92311, <br /> Fadlilys Phone: 009-421-2012 <br /> ge, 9b.U.S.DOT Desoppon(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers <br /> HM and PacYug Group(g am')l 11.total 12.Unit 13.Waste cod"Na. Typo Cuantlry WLNd. <br /> 1. NON RCRA HAZRGOUS WASTE SOLID / Ch:1 P 352 <br /> QO <br /> /lo 0 <br /> C <br /> Z Z. NiON RCRA HAZARDOUS WASTE LIOUID DIV ` G 134 <br /> 00 <br /> 7 D� <br /> d. <br /> 14 T-T- <br /> 'I <br /> .1)ABSOIn RB!dT W,�F",LTEI S#080 1059 IX_ <br /> X_ WEAR ?.I ROPRIATE PPE INN#49051 <br /> 9B 21W'ATER WIGAS#03102110 aX SS <br /> 903VU440 6-,f-.f yx ss <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby doom that the contents of this consignment aro fully and accurately described above by the proper shipping name,and are classilled,packaged <br /> marked and Iabeled1placaroed,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this compliment confmnl to the tames of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement dandfied in 40 CFR 26227(a)(A I am a large quantity generator)or(b)(dl am a small quantity generator)is tine. <br /> GeraratorslOfemes Prnted,Typed Name Signebae Month Day Year <br /> b�I up, rz-J U-)-I I 3 Z� <br /> 76.Imemafional Shipments <br /> ❑Import lip u.S. ❑Export ficin U.S. PM of eray7exit <br /> = Transporter sgnatum(ler exports only): Data tesmrg U.S.: <br /> W <br /> 17.Transporter Ackmwtedgmerl of Roo*of Matgriala <br /> OTnm i Pmded/Typed Name Sgnaloa Month Day Year <br /> y one 3 <br /> 2 Trans for 2 Pnnted7fyped Nanxf gnature Month Day Year <br /> C <br /> H- <br /> iIS.Discrepancy <br /> 15a.Discrepancy Indication Space ❑ Quantity L j Type ❑ReaHus ❑Partial Rejection ❑Fug Rated. <br /> Manifest Reference Number. <br /> tab.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> FaciMys Phos. <br /> w 1&.Signature oAhemate Fecal(or Generator) Month Day Year <br /> 2 <br /> N19.Heurdgrs,Vita Report Management Method Codes 1i.e.,codes ler hazards wasle treatment disposal,and recyding systems) <br /> 4 I <br /> l 20 esrgnated Facility Owner or -rata CeN&atim of receipt of nammous materials covered by rhe mar dist except as noted in Item <br /> 77e971dName 9gnaNre Month Dav Yaer <br /> 3 �7 <br /> EPA 7 `.-.ec.'-OS) Irevious ediliens are eescie!e. DE6SIGNATED FACILI T . TO DESTINATION STATE (IF REQUIRED) <br />