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. Apr, 21. 2011 11 : 36AM GEORGE W LOWRY, INC No, 2996 P. 2 <br /> Please Pdht or type. Form designed for use on allte(12-pitch)typewriter.) Font Approved.OMB No.2050-003& <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 a 3,Emerpency,Response Phone4,Manifest Tricking Number <br /> WASTE MANIFEST I CALQQ=15 man,12m 7 0 0 5 7 4 5 9 9 7 JJ K <br /> 5.Generaloes Name and Mailing Address Generator's$ItoAdd rear(if deferent than medIng address) <br /> CALIFORNIA GAS STATION LLC <br /> IBW E YOSENtTE etre <br /> N„1ANUTECA.CA 953M <br /> Generatoes Phone. <br /> 6.Transporter 1 Company Name U.S-EPA ID Number <br /> George W- Lowy,Inc. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> C;RLR YCUNG <br /> 8.Designated Facility Name and SlleAddrese U.B.EPA ID Number <br /> CRI Recycling 5efatce Inc. bm11 37 i <br /> 10(1 Hagan Dr.o Alle <br /> FeralllysPho ,w540M <br /> gem 9b.U-S,DOT Destorlptlon(Including Proper Snlpping Name,Huard Class,ID Number, 10.Cordshera 11.1btel 12.Unit 13.Wesly Codes <br /> HM and Perking Group(If any)) 13.Type Quantity Wtdvol. y <br /> NON RCRA HAZARDOUS WASTE soup (piI_A.HSCIREE" ' Dh <br /> Ft/,0-U Q <br /> Z 2, <br /> 3- <br /> 4. <br /> 14.Special Handing Instruction and Additional Information <br /> USE GLOVES <br /> ERGM71 <br /> IU4'OIC:E�a / <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION! I hereby declare that the contents of this consignment are fully and accurately described above by The proper shipping name,and are dassilled,padcage__d, <br /> marked and labe:adlplacarded,and ate in all respects in proper condition for transport ac ording to applicable international and national govemrnental 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 ceNly that the waste minimization statement identMed In 40 CFR 252.27(a)(if 1 am a large quantity generator)or(b)Of I am a small quantity generalor)is true, <br /> Gerarrlor'alpfferoes Pnnt ped Name Slgnawre Month Day Year <br /> 3 �. <br /> 1 16.Inkinallon9l Shipments n <br /> zI__J Import to US. ❑Export from U.S. Pod of enby(exit: <br /> Transporter signature(For exports only): Date leaving U.S.: <br /> W 17.Transporter AckwMedgmenl of Receipt of Materials <br /> o Transports Pri ted/Typed N1 / Signature Month Day Year <br /> y i <br /> = Transporter rIntedfryped Name Signa Month D ear <br /> 19.Discrepancy <br /> 180.Discrepancy Indicaoon apace <br /> ❑ ❑ 1 ❑F(A Rejection <br /> Quantity El Residua Partial Re ecUon <br /> Manifest Reference Number. <br /> lab.ATtemets Facility(orGenefator) U.S,EPA ID Number <br /> V <br /> tai Facility's Phone: <br /> 8c.Signature ofAltrimate Facility(or Generator) Mcnth Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wsata treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certificatlon of recelpl of hazardous malafts covered by the manifest except as noted In Item 18a <br /> PrintedlIyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />