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DTSC. 02715. 1480 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) PrevioA editions are obsolete. DESIGNATED FACILITM DESTINATION STATE (IF REQUIRED) <br />11683.1739 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />0101914 51 <br />JJK <br />WASTE MANIFEST <br />C A L 0 0 0 2 9 9 2 6 6 <br />1 <br />800 424-9300 oemrc <br />5. Generatoes Name and Mailing Address Generators Site Address (d different than mating address) <br />PRO -TOUCH AUTO REPAIR <br />255 MOFFAT, BLVD . <br />MANTECA CA 95336., <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />FREMOUW ENVIRONMENTAL SERVICES INC C A R 0 0 <br />0 1 7 1 <br />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 />Faalitys Phone: C AT 0 8 <br />0 0 1 2 <br />6.O 2 <br />ga <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 (11 any)) <br />Quantity <br />WtNol. <br />0 <br />1. NON-RCRA HAZARDOUS WASTE, LIQUIDS (OILY WATER) <br />.. 223 <br />Poi <br />DM <br />N <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1)DK 130217 , Ofry Water ERG#171; , <br />IX 55c4 ` <br />HANDIMtS TO BE 40B R 7RADM AND USE PPE.. <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby deaare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and Iabeledtplacarded, 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 EPA Acknowledgment 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 (b) (if I am a small quantity generator) is true. <br />�ratorslOffemes Printed7Typed Name to <br />Month <br />Day Year <br />I- <br />16.lntemationalnts <br />0 Import to U.S. Export from U.S. of enbylexit <br />M <br />Transporter signature (for exports only): Date leaving U.S.: <br />0: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Signature <br />Month <br />Day Year <br />Transporter 1 Prinledrryped Name <br />O <br />0.G <br />' <br />r-- <br />QTransporter <br />2 PrintecirTypedNarne Signature <br />Month <br />Day Y ar <br />OC <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space 0 quantity ❑ Type ❑ Residue ❑ Partial Rejection <br />❑ <br />Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />ra+. <br />Facility's Phone: <br />W <br />18c. &parwre of Alternate Fadlity (or Generator) <br />Month <br />Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />44141 <br />2.3. <br />1 <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materWs covered by the manifest except as noted in Item 18a <br />Name C Sgnawre <br />r7�0 <br />Month <br />Day Year <br />( q <br />Ck S G71,z7�V <br />I <br />1 zo <br />EPA Form 8700-22 (Rev. 3-05) PrevioA editions are obsolete. DESIGNATED FACILITM DESTINATION STATE (IF REQUIRED) <br />11683.1739 <br />