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Please print or type. (Form lesioned for use on elite (1 2-nitr.h) tvnawritar ) <br />EPA form 81OU-22 (Rev. 3-05) Previous editions are obsolete.� - ` <br />�l�of ial�'i I'w V yii �n.l Y i <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />T. Emergency Response Phone <br />�vcu. v u �V �UJV V VJ� <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />C. A I, 0 0 0 0 1 1 0 3 2 <br />1 <br />(300) 4-24-9300 <br />007124862 <br />JJ K <br />5. Gener tQ��lIm �t i ddress Generators Site Address if different than mailing address <br />�! t-! } im ,# C 9 ) <br />1130 N. WIN ST 1130 N NAIN ST <br />IMTEC.A CA 915-30 MANTEC.A CA <br />9611M <br />Generator's Phone: 209 239-CM5 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ASBURY ENVIRONNIENTAL SERVICES C A 0 <br />D 2 <br />8 2 7 7 <br />0 3 6 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Fadit Name and Site Address U.S. EPA ID Number <br />DK DIX6N <br />734)0 CHEVRON WAY <br />DIXON CA 9,5629 <br />Facility's Phone: 1707509.3'6008 C A T 0 8 <br />0 0 1 2 <br />6 0 2 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste <br />Codes <br />No. <br />Type <br />1. <br />223 <br />o <br />NON-RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) <br />0 0 1 <br />TT <br />� <br />G <br />z <br />2. <br />L <br />C� <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />N.AERG" 901: 171 * PROFILE #0,01: DK100110 *ADDITIONAL EPA COnES : 981 NONE' APPROPRIATE PERSONAL <br />PROTECTIVE EQUIPMENT �y <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 international and national governmental regulations. If export shipment <br />and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quality g erator) or (b) (if am a small quantity generator) is true. <br />000 <br />eneralor's/Offer ' Printed/Typed Name Signature <br />Month <br />Day Year <br />=-J <br />16. International Shipments <br />❑ Import U.S. ❑ <br />H <br />z <br />to Export from U.S. Port of entrylexil: <br />Transporter signature (for exports only): Date leaving U.S.: <br />UJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter ed Typed Name Signature <br />Month/ <br />Day Year <br />N <br />`• �N <br />�f7 <br />QTransporter <br />2 Printed/Typed Name Signature <br />Month <br />Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantic Type ❑ <br />Quantity ❑ yp ❑Residue Partial Rejection <br />❑ Full Rejection <br />j <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />U0 <br />18c. Signature of Alternate Facility (or Generator) <br />Month <br />Day Year <br />Q <br />z <br />t) <br />N <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Prinledrryped Name Signature <br />Montth� <br />Day <br />pYear <br />EPA form 81OU-22 (Rev. 3-05) Previous editions are obsolete.� - ` <br />�l�of ial�'i I'w V yii �n.l Y i <br />