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Please print or type.(Fom1 designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFOR61 HAZARDOUS t.Generator ID Numbef 2.Page 1 of 1 3.Emergency Response Phone 706-1TI03077522 <br /> Humber <br /> WASTE MANIFEST C A L O 0 O 0;1 1 0 3 2 1 (800)424-9300 JJK <br /> 5.Genera lN..11"'andVIWWss Generalor's S oAddress(if different than ma-:ng address) <br /> 1130 N,MAIN$T 1130 N MAIN ST <br /> MAN'W{ A CA 95336 MANTECA CA 95336 <br /> Genefato(sphone; 1209 239k06156 <br /> 6.Transpoitei I Company Name U.S.EPA IDN"Zer <br /> ASBURY ENVIRUWFNTAL SERVICES CAD 0 2 0 2 7 7 0 3 6 <br /> 7.Transporler 2 Company Name U.S.EPA IO Number <br /> 8.Oesgnateed}�Fad ityyyNaarme and S ie Address U.S.EPA ID Number <br /> 73.�(3'CHEVRON WAY <br /> DIXON CA 9!A- 2O GAT0� OO1.�0a2 <br /> FaciWs Phone: 707)6433-60013 <br /> ga. 9b.U.S.DOT Desc6p6bn(u,uudrg Proper Sh'W.ng Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Wase Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wt.rvol, <br /> 0 1 NUN RC,RA HAZARDOUS WASTE,LIQUID(OILY WATER) 001 T T G 223 <br /> Z. - <br /> w <br /> I <br /> to <br /> 3. .Ju(_ 2 7 201/ <br /> 4. ENVIRONMEN TA.L HEALTH <br /> DEPARTMENT <br /> 14.Special Handing Intrusions and Additbnal lnfomrat'on <br /> NAERG# 4181:171 = PROFILE #981.DI(100110 =-EMERGENCY CONTACT:CHEMTREC 1-300-124-9300 F <br /> ADDITIONAL EPA COOLS;901: ,NONE -1 APPROPRIATE PERSONAL PR07ECTIVE EQUI13MENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I herebydedare that the contents of Ws consignmenl are fvV. and accurately doscribed abvie by the proper shipp?ng name,and aredassihed,packaged, <br /> marked and labeliapfacarded,and are in a+kespects In proper condtion for transport according to aWkable WerwCo W and na[onal gownrimentai mg*tiw&It export shipment and I am the Primary <br /> Exporter,l certify Ihat the contents of itis consignment conform to the terns of the attached EPAAcvwq"gn%nl of Consent. <br /> 1 certify Thal Iho,s�sto m`n'miration s!alemenl Ntentifed ind0 CFR 262.27(a}(it I am a large quan5ty generator)or(b)(f I am a sma7 lity generator)is true. <br /> GeneraWsn3Refo(sPrintedzfypedName Sgna,, 11'anth Day Year <br /> —z iS.In'RfnaConal Shlpnlent <br /> F- ❑fmPorttoU.S. ❑ExportfromU.S. Portofenhylexit <br /> z Transporter synature(for exports only): Date fearng U.S.: <br /> 13d 17.Tianspoft kwMedgmenl of Rece'pt of 64ateda's <br /> W it or�LP+intedrT Nam 1 S:nature Month Da Year <br /> O O rJ e y t (1"6 g y l�� <br /> a <br /> Q Transporter 2 Prinled>Yyped Name Signature Month Day Year <br /> 18.Discrepancy' <br /> 183.ascrepancy Indra)on Space ❑ Quantity [:)Type ❑Residue ❑Pa(W1 Re ecfon ❑Ful Re eceon <br /> Manifest Reference Number: <br /> 18b.A11emate Facility(or Generator) U.S.EPA ID Number <br /> t3 <br /> U <br /> W Fao.ys Phono: <br /> w 18c.SfgnalweolAtlernateFaoity(orGenerator) Month Day Year <br /> Q <br /> z <br /> 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ueatmenl,daposal,and recycling systems) <br /> LLJ f, 2. 3 d. <br /> 20.Desrgnated Faa?ty Owner or Ope+a or:CertiBcat on of recti pl of hazardous maleriat3 co;zred by Iha manAest excepl as nded in tlem 18a <br /> I PrintedrTyped Name S:w Month Day Yea, <br /> aN 17 15 <br /> EPA Form 8700.22(Rev.3-05) Previous editions ate obsoiete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />