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a <br /> Form Approved.OMB No.2050-0039 <br /> typewriter.) g 4.Ma desl7 eking Number _ <br /> Please(Form designed for use an elite(12-pitch)n/P . 2 Page 1 of 3.Emer enc Raeponse Phone .0 tl /1 k�1 ; <br /> I.Defers rlD Number (800;42i�:-9..00A ' L�eJ JJK <br /> UNIFORM HAZARDOUS _ j r, ;1 F,5:; ' 5 <br /> WASTE MANIFEST �„,y GeneratMs Site Address(M GAerenl than maTng address) <br /> 5.Genemtq(st�'aT fflnl M?il.}yf; nasi <br /> 3727 CLARK OR. a 20 <br /> 209 4$2-194' U.S.EPAID N mpar <br /> Generator's Phone: - C q l�U ra 8.7 7 J 3$0 <br /> 6.Translm9?[z40{4 b i0NPv1ENTA.SEfi41Ca9 <br /> U.S.EPAID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPAID Number <br /> A.Designa�dF�dl�ly Na�pe_arA�t��Prd��e�-,i;Fy L;..^-,. <br /> g ANNINGAVENUE rt» CAL000102751 <br /> Fedliys Phone: � 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a .U.S.DOT Desaiptl0n(mctud Proper Shipping Name,Hazard Class,ID Number No Type Ouank WUVOI. <br /> . � n9 <br /> HM and Packing Group(g any)) lAKU U(L) Z2: 1.-- <br /> 1, ..:n✓v%1+1-.n Ut.rua Ya 7I C. <br /> Lill. :;3(Uz, U UIL/ G I — <br /> � 00 . T T .H i., -� - <br /> o <br /> 2. <br /> World Oil-San Joaquin, L tCt receive <br /> 3. your waste, and has received the waste. -Our EPA ID Number is CAL 000 102 75 <br /> 4. <br /> 14.S cialHandling InsWCPans and Additional Information <br /> rfcP ginb ousel I tix'*t/TREC 1-80D-A.'2.49300 *APPvGPRiRF -PROTECS!SE£QU!PMEN?' `EiAERGE t„ <br /> i ; 1 <br /> E,,&f 2- 3Wq r 1 <br /> ment are fully and abourateli descnbeE ab by the proPersa.If e 9 name,ardme are classified,parkayed, <br /> m m er re that to for transporta¢OmOg t0 aPPf'ce6fe iprsmagonsl arx(mbonal govem�ental regNatlons.It export shipment and am me Primary <br /> 15. GENERATOR'gIOFFEROR'S CERTIFlCATION:Iherehy declare that the contenten of thrscensgn ` ! <br /> marked and labeledlplaomed,and are in an respects, P P nt of_ Mian r <br /> Exporter,I cerBfy l�ald!ecantents of Nis comp mee. <br /> et contorm to the terms al the atta<had EPAAcknowletlgmp I' _ / Yag <br /> I cemy that theiwasle(nmim¢a0on sutemenl id 7Xd m 40 CFR 262.27(a)(d I am;a large Wanbry SM�.�r33)or(b) dl arrta sma119uanmyge �^..� :r <br /> Genendoes101femTAPdOIAdljyP�Nam? . ....-..__i <br /> r--1El Export Senb <br /> am U.S. `Port of ylexa. <br /> F 16.Intemabonal Shipments LJ import to U.S. Date leaving U.S.: <br /> = Transportersgnature(forexponsunty): c-] Dry . Yea <br /> W17.Transporter Ackww'Iedgmentot Remiptof Materials !_ <br /> 71 <br /> Transporter 1 PrmWF.yP0Neme Yn' F <br /> '-1 <br /> Month Day Yee <br /> y <br /> QTransporter 2 rim dRyped Name <br /> r <br /> Full RejsrArn <br /> 18.D'iscrepanwY Partial Rejection <br /> ❑ <br /> 18a.Discrepancy Indication Space � Quantity �Type <br /> ❑Residue <br /> Mandesl ReferenceNumber. U.S.EPA 10 Number <br /> 18b.Alternate Facility(m Generator) <br /> J <br /> C1 Month Day <br /> LL Facilitys Phone: <br /> W 18c.Signature Or Alternate FadlOy(Of Gerarar)r) <br /> Q <br /> w 19.Hazardous Waste Report Management MethodCodas G.e,��br hazardous waste beaMenC disposal,and recycling systems 4 <br /> 2. <br /> i <br /> C,UcaUDn of m mpt m hazardous materials covered by Ne manifest except as Maid in Item 18a Month Day <br /> 20 Designated Facility Owner or Operztoc <br /> Nemo ..1� ,r- ,�yam- G�,�ars�'y"i ./ }/i{ ' <br /> Pnn YP�.,!^ ,f�f/ ' <br /> -- oESIGNATED FACILITY TO GENERF <br />