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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />DTSC.01600.1340 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10879.2177 �� <br />UNIFORM HAZARDOUS <br />2. Page 1 of 3. Emergency Response Plane <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />1""erato"Ol'imber <br />C A L 0 0 0 3 1 9 9 0 1 <br />1 <br />007269038 J J K <br />5. Generator's Name and Mailing Address GeneralDes Site Address (if different than mailing address) <br />CALIFORNIA FUEL SUPPLY INC 2575 COUNTRY CLUB BLVD <br />587 YGNACIO VALLEY ROAD <br />WALNUT CREEK CA 94598`1 STOCKTON CA 95201 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Nameag;k2/ <br />6--,71,1VE���� ��� <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />CROSBY & OVERTON <br />1630 W. 17TH STREET <br />Facility '5=432 BEACH 90813 CAD 0 2 8 A 0 9 0 1 9 <br />ga. <br />9b. U.S. DOT Description (raiudirg 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 Grarp Cf any)) <br />Quantity <br />Wtivol. <br />0NON <br />1. <br />RCRA HAZARDOUS WASTE LIQUID <br />00 ( <br />Q <br />30 <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />WEAR PPE, ERG 0171. EMERGENCY CONTACT: CHARLES SEATON 5104761740 Ar Seq o I <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 tabelwWacarded, and are in ad respects In proper condition for transport according to applicaN international and national governmental regulatim. 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 AckriowilidArient qJ Consent <br />I certity that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity gen ) orf) (if l am iijimall quantity generator) is true. <br />toes/Offeror's Prtnted[Typed Na Si Month Day Year <br />16. International prrnents <br />❑ Import to U.S. ❑ Export from U.S. Por of entry/exit <br />Transporter signature (for exports only): Data leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />a <br />Transporter 1 PrntedfjyQed Name Srgnatu Mom Day / r <br />/ <br />�- / <br />Z <br />Tran"r 2 Prnled/Typed Name Month ay Year <br />i- <br />18. cy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ R.04' <br />' ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />7 <br />V <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste tieatmem, disposal, and recycling systems) <br />LU G <br />1 <br />1 <br />2. y <br />3. <br />4. <br />20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as riled in Item 18a <br />P yped Name�-.`^� t th Day Year <br />lS�-t. � 1� SC'A v (0 111 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10879.2177 �� <br />