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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />D❑C. 0 2 4 6 7. 14S4 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previouseditionspre obsolete. - DJigfNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />11522.1427 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />14. Manifest Tracking Number <br />WASTE MANIFEST <br />C A L 0 0 0 2 9 9 2 6 6 <br />18w 424-9300 aemE-- <br />010197740 JJ K <br />5 Generator's Name and Mail in Address Generators Site Address (d different than mailing address) <br />PRO -TOUCH AN REPAIR, <br />255 MOFFAT,BLVD <br />MANTECA CA 95336 <br />Generators Phone: 2, 0 9. •. 2 3 9- 9 2 5 0, <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />FREMOUW ENVIRONMENTAL SERVICES INC . C A R 0 0 0 1 7 1 0 1 7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />DK DIXON <br />7300 CHEVRON WAY <br />DIXON CA 95620 <br />Facility's Phone: 707 693_6008 C A:,T 0 8 0 0-1 2 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 />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. NON-RCRA HAZARDOUS WASTE, LIQUIDS (OILY WATER) ;',.r <br />; w ;i!•. K <br />'",�AAa <br />' <br />3 v <br />W <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1)Oliy Water ERG#171 r'a r!•. <br />tXSSy <br />HANDLERS TO BE 40HR TRAINED AND USE PPE. <br />15. GENERATOR'S/OFFEROR'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 and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmeni 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 a small quantity generato is W <br />Generators rors Pnnted/Typed(NN y� signa M�� 1D� Year <br />13 <br />-J <br />I-- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />1 1 Signature MonthDay Year <br />Transporter rnnte yped Name <br />N <br />561-10571_1 13 <br />wf <br />za <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue ❑Partial Rejection Elull Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />19. Hazardous Waste Report Managrnent Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3 <br />4. <br />20. Designated Facility Owner or Ope . Certification of receipt of hazardous materials 2t by the manifest except as nded in Item 18a <br />PrintedirTyped Name Signature Month Day Year <br />Q5 IZ31'"d <br />EPA Form 8700-22 (Rev. 3-05) Previouseditionspre obsolete. - DJigfNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />11522.1427 <br />