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Please print or type. ---- <br /> ype. Furrn Approved.OMB No.2050-0039 <br /> e rat I 2.Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> r �D�m b 0 4 1 4 8 7 2 (800) 424-92% <br /> UNIFORM HAZARDOUS1 C 012772978 FLE <br /> WASTE MANIFEST <br /> 5jr f sNat <br /> a Maili Addr roduCts, LLC 1is Wrral6 tress(it different than mailing address) <br /> `' <br /> e oast <br /> P_0_ BOX 80249 85 E LOUISE AVENUE <br /> Rancho Santa Margarita, CA 92688 9130—s2oo LATHROP, CA 95330 <br /> Generators Phone: <br /> 6.Transporter 1 Company NameU.S.EPA ID Number <br /> BELSHIRE CARO 0 0 1 8 3 9 1 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Des rated Facili ame and Site Address U.S EPA ID Number <br /> eMlenno erdoon CAT 0 8 0 0 1 3 3 5 2 <br /> 2000 N_ Alameda St. <br /> Compton, CA 90222 <br /> (310) 537-7100 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 ContairPrs 11.Total 12.Urit \ 13.Waste Codes <br /> HM and Packing Group(if any)) Nr.. Type Quar*ty WtNol. <br /> 1. UN1203, Gasoline Mixture, 3e PG II G 134 <br /> X <br /> N1 I&U <br /> z Z. <br /> W — <br /> c� <br /> 3. <br /> 4. <br /> BEcI • `' 98 99� �oib;ue <br /> 14.Special HandlingInstructions and Additional Information L <br /> ERG#: 125 PROTECTIVE CLOTHING EP CCN: 205882 <br /> Ga3oline & Water <br /> ZxSS � X3dop <br /> 15 GENE RATOR'SlOFFEROR'SCERTIFICATION: I hereby declare that the cements of thiscons consignment are fully and accurately described above by the proper shipping name,aid are classified,packaged, , <br /> marked and labeledlplaawded,and are in all respects in proper condition for transport according to applicable intemalienaland national governmental regulations.ll export shipment and I am the Primary <br /> Exporter,I cerify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgmenl of Consent. <br /> I certify(hat the vraste minimization statement idcnbf!ed in 40 CFR 26227(a)(U I am a targe quantity generator)or(b)(d l am a s I qu ntity generator)is true. <br /> Signature Month Day Year <br /> timerraoesloffefors oPrinted/t of <br /> 6G �� <br /> Larry Idoothart of BE9I on behalf of generator l <br /> J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of enlrylexil: ..__ <br /> ? Transporter signature((or exports only): Date Icarmg U.S.: <br /> iX 17.Tr-.nsporler Acknowledgment of Receipt of Materials <br /> LLI Transporter 1 PrintedrTyName [� Signature Morth Day Y00arrlei 6'ci Ii <br /> Tj <br /> Z Transporter 2 PrinledrTyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy ( <br /> i6a.Discrepancy Indication Space ❑ Quantity ❑Type Ll Residue ❑Partial Rejection l full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> - U <br /> ra+ Facility's Phone: Month Day Year <br /> LO 18c.Signature of Allernale Facility(or Generator) <br /> W <br /> a <br /> z <br /> 19.H zardeus Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' 2 r <br /> 4. <br /> 20.Designated Facility Oveher or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name ,� ` Signature Month Day Year <br /> 0 (� i (►'D AM Ira (e (����� 0 <br /> EPA Form 8700-22 Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 191a1418 <br />