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Please nrint or tvnL-- (Form dpqionpd for tjqp on elite (1 9-ni&PwfltA.r) <br />40 Fnrm Annmv.-H ONAR Nn qnrn-nnAq <br />ti -A t-orm btuu-zz (Kev. j -m) tirevious eanions are obsolete. DESIGNATED FACILITY TO GENERATOR: <br />UNIFORM HAZARDOUS <br />1 1. Generator ID Number <br />2. Page I of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 00fe.'709881 FLE- <br />WASTE MANIFEST <br />CAF. 190 060 <br />.,, . <br />1 <br />666-3.33-9222 <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />2.710 Locnals'. 11d, <br />ptoOK001 Cal 95206. <br />,Generator's Phone: �,' ?04 4A7- 16; R <br />6. I-ransportef TU.ompany Name U.S. EPA ID Number <br />Adwomeesti Chavoical Tvansrert M0000705401 <br />7. Transporter 2 Company Name- U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />VA,wexbmak- Oil Tranrfer,LLC <br />.5300 Claus load <br />Rivarbat&, CA 93367 <br />Facility's Phone: 209-863-8:,81 C 00019081 <br />9a. <br />9b. U.S. DOT Description (including 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 Group (if any)) <br />Quantity <br />Wt./Vol. <br />1. Non RCUA Hamardous Waste, Liqtaid (Oil) <br />221 <br />0 <br />I <br />rtg <br />I-- <br />2. <br />U.1 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />Projeat Number: CV00450 <br />16- <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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Off ror's =nn ype a Signature Mon ih Day Mar <br />S Te vp- <br />=.j <br />16. International Shipments <br />FlImport t(U.S. ❑ Export from U.S. Port fen exit: <br />Transporter signature for exports only): Date le U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name ture on Day ea <br />0yr <br />11n <br />Transporter 2 Printedfryped Name Sigfture- month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity ❑Type 0 Residue El Partial Rejection EI Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />LU <br />18c. Signature of Altemate Facility (or Generator) Month Day Year <br />0 <br />rn <br />19. Hazardous Wase Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />1 7- <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of re of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedfryped Day Name <br />Sint <br />74gatirt th Yea <br />elelll 1<�er Al Z, I I I/MonID I a '121 9 <br />ti -A t-orm btuu-zz (Kev. j -m) tirevious eanions are obsolete. DESIGNATED FACILITY TO GENERATOR: <br />