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Please print or type.(Form designed for use on elite(12-pitch)lypevaiter.) Form Apptoyed.OMB No.2050.0039 <br /> UNIFORM HAZAR40US i.Generator 10 Number2.Page 1 of 3.Emergency Response Phana 14,hlanIfesi Tracking Humber <br /> WASTE MANIFEST C A L 0 0 0 0 1 1 0 3 2 1 (RHO) a2� 9300 014644979 JJK <br /> S.Genera s rr>Qan�t �Ad�r R Generaloe-s SiwAddiess tit dllferent Than mVing address) <br /> 1130 N. 14AIN ST 1130 N MAIN ST <br /> MANTECA CA 95336 MANTECA CA 95336 <br /> GeneratoesPhone: 209 239-0665 <br /> 6.Transporter 1 Comp�aany Name U.S.EPA ID Number <br /> AS13U73Y ENVIRONMENTAL SERVICES <br /> 104 D $ `7 D3 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.0asgnateclFarz4 <br /> DK ffl Na and Site Address U.S.EPA 10Namber <br /> 7300 CHEVRON WAY <br /> DIXON CA 956.20 <br /> FacifitysPhone: (707)693-60013 C A T .- $ 0 0 1 2 6 0 2 <br /> ga. 96.U.S.DOT Dw*on(including Proper SNW.ng Nams,Hazard(lass•10 Number, f0.Coolatners 11.Total 12.UNI <br /> Hill and Puking Group(if any)) No. Type Quantity Wlivoi, <br /> 13.Waste Codas <br /> NDN—RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) 0 0 1 T 7 G 223; <br /> to LJ <br /> E j <br /> ENVIRG <br /> I <br /> I T <br /> 4' DEPARTMENT <br /> 14.speoat Handing lmfnxWs andAckfumai lntonw on <br /> NAERG# 9131 : 171 PROFILE # 9B1 I. DK100110 **EMERGENCY CONTACT.- CHEMTREC 1-000- <br /> 424-9300 * ADDITIONAL EPA CODES : 9B1 t r NONE A APPROPRIATE PERSONAL PROTECTIVE <br /> EQUIPMENT <br /> 15. `GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of tilts cons!gnment are laity and accuralelyd6suited above by the proper sh pp!ng name,ani are classifed,packaged, <br /> marked and fabe!ed'pfar:arded,and are In all respects In proper cond.-Con fee Vanspod a"d'ng to af#.�able Intemalonatand natonai garenvmenlal regutaeons.if export shpmut and t am Ura Primary <br /> Exporter,I ce"that the opnlents of this consignmenlconform to the terms of the attached EPAAcknoMedgnlenl of Consent <br /> I certify that the waste min rn�z6on statement Idem led In 40 CFR 262.27(x)(if 1 am a Paige qua ARy generaloi)or(b)(if I am a una9 aMty genetaler)is We. <br /> Generalorsl0;feroes PM rryw >e 1 S.'grtaluro Month Day Year <br /> a42 '=� <br /> -i TO.International Shipments <br /> ❑Import to U.S. ❑Expod from U. _ Pat of enUyfex,7; _ <br /> Transporter s!gnature(for experts only): Date WON U.S.: <br /> 17.TraasporierAc wA'edgmenlcf Recefpl of Materials <br /> Transporter 1 PrinlediTyped Name Signature tdonth Day Year <br /> Transporter 2 Prfnfedrtyped Name a e Montli Day Year <br /> 10,Discrepancy <br /> 18a.DsaepancyfndrationSpaco ❑N nti <br /> ty ❑Type ❑Resdue ❑PaR+al Rr;;ecton ❑Fu7 ReeVJon <br /> Manifest Reference Number: <br /> 18b,Alternate Faciaty(or Generatot) U.S.EPA ID Number <br /> U <br /> Fawys Phona: <br /> H18c.Signature ofAtemateFa"Io(Genetatr) month Day Year <br /> Q <br /> z <br /> 19,Hazardous Wasts Report Managemenl Me"Codes(Le.,codes for hazardous waste Veatmenl,asposal,and regd'--ng systems) <br /> A 1. 2. 3. 4. <br /> 20,Designated Fabt;IyONnet or Gperalor:CeBlcarom of iece.'ptof hazardous rmateria mvered by the man;tesl except as nded in Item 18a <br /> ftled/Fyped Namo l ` S?gnatura htonth Day Year <br /> GtJ CCZh r.r G, ,, 0, 1 ) � I trl <br /> EPA Form 8700.22(Rev.3-05) PwAouseditions are o6soldte. DESIGNATED FACIE TO DESTINATION STATE(IF REQUIRED) <br />