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Please print or tyle. (Form designed for use on elite (12 -pitch) rypev/riter.) <br />FortnA roved OMB No 20500039 <br />EPA Komi 8700-22 (Rev. 3-05) Previous midtons are Obsolete. <br />DESIyj AtEb FACILITY TO GENERATOR STATEr(IF REQUIRED) <br />-r <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone ." <br />PP <br />1: Nanifut TraoYJng Number <br />WASTE MANIFEST A L 0 0 0 3 1-9 4 5 9.. <br />1' ( <br />0)42493001 <br />0,0100915780 <br />JJK <br />S. Generators Name and Mailing Address Generators Site Address (ifdiReram thenmauing address) <br />WEST VALLEY AUTO. SPA ARID LUBE - VVIES 197 - <br />2613 W GRANTLINE ROAD <br />CA 9M4 <br />Phone <br />GeneraTRAs 1 <br />6. Transporter 1 Company Name - <br />U.S. EPA ID Number <br />ern I v M p F R CES <br />C A D 0 2 <br />8 2 7 7 0 3 6 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />DINNENNO / KERDOON <br />2Ot7�OP�ANEDASTREETCONOA 90222 <br />C A T 0 8 <br />0 0 1 3 3 5 2 <br />Facility's Phone: n { Q R17-71 <br />' ga <br />gb. U.S. DOT Description (Including Proper SNpping Name, Hazard Class, ID Number, <br />10. ContaMere <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (If any)) <br />. <br />'�.Ouantity <br />WtNal, <br />13. Waste Codes <br />No. <br />Type <br />tY <br />1. <br />Pd 4nRA Ka,,zkADO(JS WASTE, LIQUID (OILY WATER) <br />OI <br />M <br />O 0 <br />G <br />Z <br />2. <br />W <br />CD <br />i <br />3. <br />1 <br />) i <br />r <br />4. <br />14. Special Handling Instructors and Additional Informallon <br />E7NfROENCY CONTACT : CHEMTREC 1-FO&424�xG0 NAERW 681: 171 ' PR09LE 4 9811i.- <br />335EU OILY WATER'?G <br />A1101 'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ere fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/plararded, and are In all respects In proper condition for transport according to applicable International and national governmental <br />regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the techs of the attached EPAAckngWledgment of Consent <br />I certify that the waste minimization statement Identified In 40 CFR 262.27(x) of I am a large quantitygenemtor) or (b) (HI am a small quantity generator) <br />is We. <br />` <br />Generatoes/08erors PrintediTyped Name Signs <br />' Month Day Year <br />16, International Shipments <br />❑ Import W U.S. ❑ Export from U.S. Pat ofentry/adC <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Mlatmals <br />y. <br />Transporter 1 //11 PrinledlTypr Signature <br />Month y <br />0e <br />(` 7 (V ./ <br />( <br />,ar <br />, <br />a <br />Transporter 2 Pdnredrfyped theme Signature <br />Month Day Year <br />C <br />r <br />1 <br />18. Discrepancy <br />I <br />I <br />18a. Discrepancy Indication Space ❑ Quantity El Type ❑Residue <br />Residue <br />El Rejection <br />❑Full Rejection <br />Manifest Reference Number <br />led. Altemate Fadllty (or Generator) <br />t <br />U.S. EPA ID Number <br />- <br />U <br />LL <br />Faality's Phone: <br />w <br />18c. Signature ofAltemate Facility(or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />r] <br />1 / 7 / -eR3 <br />! <br />2. 3. <br />4. <br />20. esrg� ted Faci ir�er or Operator. Certification of receipt of hazardous materials covered by the manifest except In Item 16a <br />��� <br />PrintedR ed Name <br />�� ^� _ Signatu <br />' �U I � V � f <br />Month AD,ay Year <br />V W ' <br />1I <br />r- <br />EPA Komi 8700-22 (Rev. 3-05) Previous midtons are Obsolete. <br />DESIyj AtEb FACILITY TO GENERATOR STATEr(IF REQUIRED) <br />-r <br />