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I <br /> Please print or type (Form designed for use on elite(12-pitch)lypewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS S.Generblor'IDNumbm /1 — 77;-- 2:Page1 of 3.Emergency Response Phone 4.Manuost Tracking Number <br /> WASTE MANIFEST 16AI 060-488 A2 ` — 1i—) 0-1,3077139 1 JJK <br /> 5.Generator's Name and MaltrgAddres, Grabseldrs.SiteAddress(it different than mailing address) <br /> WEST LANE CHEVRON- <br /> 9464 WEST LANE <br /> STOCM'TON CA . 96210 <br /> Generators Phone: 1 <br /> 6.Transporter i Company Name ,y, - U.S.EPAIO Number <br /> 7.Transpoder-Company Name <br /> 8. <br /> us <br /> q <br /> 8.Designated Facility Nam and Site Address 't U.S.EPAID Number <br /> OEINIENNO /; 8150011 <br /> 2000 N.ALAMEDA STREET <br /> WNIPTON CIA 90222 0ATOfl0017352 <br /> Facilt/s Phone: ,. �'an^ <br /> ger, 91h.U.S.DO Deurfpton(indudrg Proper Shipping Name,Hazard Class,10 Number, 10,Containers 11.1.1.1 12:Untt 13.Waste Codas <br /> HM and Packing Group(9 any)) No. Type Quantity WINol. <br /> 1. <br /> o MON-R09A HAZARDOUS WASTE,LIQUID(OILY WATER) <br /> Z F' Dna <br /> z 2. <br /> 3. <br /> 4. 1.41 <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENOY CONTACT-,CHEMTREC 1-800-424-9300 NAERG#f 991 s 171:* PROFILE 991:45018014 OILY <br /> ' WATER* PO4 A110190344¢APPROPRIATE PERSONAL PROTECTIVE ERUIPh U / <br /> 15. GENERATOR'SRIFFEROR'S CERTIFICATION: Ihereby declare[hat the contents of this consignment are holy and amaalely descnthed 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 regulators.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 EPAAcknovdedgment of Consent. <br /> I cently that the waste minimization statement Identified In 40 CFR 262.27(x)(f I am a large quantity generator)or(b)(if i am a small quantity generator)is We. <br /> Generatoesl0tierors Pdn[edrryped Name 1 Signature I r Month Day Year <br /> —1 16.International Shipments ' <br /> F ❑Imp ut to U.B. ❑Export Tran U.S. Pod of entry/exib <br /> E Transpoder signature(for exports only): Date.leaving U.S.: <br /> w 17.TranspoderAcknowledgment of Receipt of Materials <br /> Trans rt�S1'((PdnledR�—amee / Signature Month Day Year <br /> Z Transporter 2 FruttedlTyped Name - 1"SlgrWwe Month Day Year I <br /> Od <br /> 4. 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 1:1 Residue ❑Partial Rmedien El Fail Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) _ U.S.EPA ID Number <br /> U <br /> u FaciliHs Phone: <br /> w 18c.Signature ofAllemate Fadlity(or Generator) Month Day Year <br /> ZZ <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1 2 3. 4. <br /> 20.Designaled Fa ItyOwnerm0pemWr:CaNlwtanofmmipl-IlhazaMous materials covered hythe manifest except as acted In ltgrrrlW t , <br /> VIII' Pdnledlfyped Name .-1 Ye <br /> ( Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESISpOATEDFACENERATOR STATE(IF REQUIF(ED) <br />