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1 <br />4 <br />4 <br />Please print or type. (Form designed for use on elite (0h) typewriter.) <br />0 <br />Form Approved. OMB No, 2050-0039 <br />UNIFORM HAZARDOUS <br />Generator ID Number ~ <br />2. Page 1 of 3. Emergency Response Phone <br />d. ManifestTracking Number <br />WASTI MANIFEST <br />p }£ 4 r <br />'AL`'" f <br />5, Generator's Name and Mailing Address Generator's Site Address (If different than mailing address) <br />5 NC'R.Ti MACH€.TtIUR DRIV TRLt�3; SHOP <br />rRAC" CA 9376 <br />Generator's Phone:2 =i ._ . 3 3, -• 3 1 tr <br />6. Transporter f Company Name U.S. EPA ID Number <br />A XLFrN' x :TEM',� T14C T;:f1000050930 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address SAFETY—MEN SYSTEMS, IN 000618 U, S. EPA ID Number <br />1722 COOPER CREEK ROAD <br />I)ENTOE, TX 76208 <br />340-483--5200 TXD077603371 <br />' <br />'Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (ff any)) <br />Quantity <br />Wt.Nol. <br />cc # <br />WASTE F LAM,HBLE LIQUIDS. N. 0. S. <br />i; <br />F <br />001 008 Lola <br />o <br />GASOLINE) <br />t.jti ^.."' 3 PG 11 V '3 Al F.1 'i`" ". '.^' <br />, . - <br />➢ � i 4UTS. a! <br />.{. j i..l d V .4/s� a..,A� _ _ <br />r.r..r <br />Z <br />2. <br />LU <br />4. <br />14. Special Handling Instructions and Additional Information SK TR CK # 108 4 2 3 45 4 000 2 u d 2 50 3 <br />6—mm 128 i <br />+.T i TO Or' ra 'i jt}-,� .` i'. i ria �{ •ttZ "1 `fid .''r.1; <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 intemational 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 EPAAcknowledgment 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 ami small quantity generator) is true. <br />Geperator'slOfieror's Printed/Typed Name Signature Month Day Year <br />16. International Shipments <br />i— ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature ' d Morjth Day Year <br />r <br />F w <br />Z <br />Transporter2 Prmted/Typed Name ` ' Signattiie-� ._ -• �s Month Day Year <br />rr <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Partial Refection Full Rejection <br />Manifest Reference Number: <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facilitys Phone: <br />Lu <br />18c. Slgnature of Altemate Facility (or Generator) <br />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. <br />20. Designated Facility Owner or Operator: Certification of receipt cf hazardous materials covered by the manifest except as ntted in Item 18a <br />Printed/Typed Name Signature Month Day .' Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />1.P214t') 6t 4 9 4' S.i— .t.0 <br />