|
Please print art , (Form d -mil nod for use on olitO (12 -pitch) tyowhar.)
<br />UNIFORM MAZARVOL, 1. Generate rn Number 2.
<br />WASTE ietAWIMUT C A L 0 0 0 s 1 S 1
<br />5. G81Wratol's Nam a and Isiadfnp Addrgsa
<br />CALIFO ITA FUEL SUPPLY ING
<br />W1 YGM'010 VNIEY MAD
<br />WALNUTGREEK CA W1157)&
<br />2575 GMqRY CLUB EUD
<br />SiMICTON
<br />For'it;.Approved, QM3 No, 2050.uU'8t1
<br />h-ut Tracking Numbor
<br />.dd�Bael) "
<br />ICA
<br />f
<br />95243
<br />- S. Des gn6led Fsdltg• Name and Brie rklM34 I.S. EPA ID Number
<br />CRIDSOVA GM -TON
<br />162110 UV. 17TH tJrREET
<br />R,a�ne.•11�l1I1 CA CAD028409019
<br />fadYty's o?`?r„ __
<br />ga, 8b, U.S. Doi beseription (nc!uding Proper Shlpping Noon, Hazard Case, ID Nualber, 10. Cpotelnerd . 91.7e1e1: 12, t!I>It 13. Wdsto Godus
<br />ardl packing Group (if any)) No. Tytro QustdRy WLNIOL
<br />WASTE L(Q(AD
<br />:i?)FW PPE, ERG# 171. 2,191rIONCY C0h�"Tk,T. CrHAF'e-ES SEATOy 51047&1740 Az `�O'q 01
<br />69WERATOR'SMFnROFUS CERTIFIC1kTIUN: I hareby dae!are that the cant nts ci in swnsfgnmar Eta (ulty and pm alsly daacnbad abov7 by thu Jro� shipping namo,:.-W. Nv du,: led, paciayr
<br />marked and taboisd/p acardutl, and era n a l re;oods In proper cakdltle t for transportaxarding to app!ido intatnatlmland naknol governmantal ragulat�, !f oxport -„lament ar,d I em the Primmy
<br />Exporter, I c,e* lhetthe canten(a of this cansgnment confom t0 $latamle Of Ota attached �3AP,Ckrt4Ytt d neu( 'concunt
<br />I certify Drat tho wdt to minimi d@on.stalement!derlU@ad in 40 CFR 26227(a) (I t am a !arae qusllUty gen rat r) or ) Qf t sm , n0l gWrillly gsneretol) is he.
<br />tars/Ofterol's PdritodlTyped NJ lu
<br />o Mcwth Gay
<br />1 711
<br />F5
<br />10, Ha«ard0us Ylasle ?apart f�danagi:mant.MathOd Codas (Le., codas for h=rd.= waste treetnram, cilspocab and reeyclinq s_lstema)
<br />20. ❑ecignated Facility Owner or Operator: L4iOWil0n cf recalpt of h3.14*94 maVirruI5 ooyured by he mgniftm uxcupl ae rcted In hie lila
<br />P rite ,paTR= S!gnatua
<br />v t
<br />n d10A-22 (F1,Pv. 3.05) Pravlws edIllons aro dsolete, DE$[ NA TED FACILITY TO DESTINATION STATF- (IF REGUIRECI)
<br />.,,,, .,� „-in-snrr•n- ter- nn -r rn� i � : rn
<br />t e. nnunrauaar muN °d. LJ Unpart t7 l °.
<br />ii Expait tom 11,S. Port afu klexlL
<br />7ranaUarWr algtatu a (ia oxpotta 0ntyj
<br />Data leaving U.S.:
<br />L Lf
<br />17, TtunspcutetAc}mowtad{gnantof HEcetpt Ot MdW&
<br />liar 1 P 6nta u acne / / f
<br />:T�rvInsp—,fter2
<br />a"Ignatu} i
<br />With Gay Yaar
<br />V)
<br />- (/�
<br />Fr ltadliyped NAMQ -
<br />sIgo u
<br />(tlonul BY Yaar
<br />t
<br />i
<br />Ia,Dtscropancy_--
<br />`
<br />itit, dh7Cre94nay )MICS lcn Space❑ GuanL'ly ❑Hype
<br />�II
<br />'J Rus:dua
<br />^–
<br />U Fo'al Relactlon
<br />❑tiIAR*eLm
<br />ManileatRa(etcnca Nlnt�or
<br />—
<br />'
<br />18b. Altsrnale Faa!lity (or GenornWr}
<br />U.S, EFA IG Number
<br />ii
<br />Facdl!y's PhoncK -- .
<br />,_
<br />100, s9pohWu or Alternate 11=4y cl4—'eaOf)
<br />A1onl1 Ray Yuan
<br />I i
<br />F5
<br />10, Ha«ard0us Ylasle ?apart f�danagi:mant.MathOd Codas (Le., codas for h=rd.= waste treetnram, cilspocab and reeyclinq s_lstema)
<br />20. ❑ecignated Facility Owner or Operator: L4iOWil0n cf recalpt of h3.14*94 maVirruI5 ooyured by he mgniftm uxcupl ae rcted In hie lila
<br />P rite ,paTR= S!gnatua
<br />v t
<br />n d10A-22 (F1,Pv. 3.05) Pravlws edIllons aro dsolete, DE$[ NA TED FACILITY TO DESTINATION STATF- (IF REGUIRECI)
<br />.,,,, .,� „-in-snrr•n- ter- nn -r rn� i � : rn
<br />
|