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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST J CAL0002S6804 1 1310 675-2500 004202583 JJ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> CFJ PROPERTIES <br /> 333 HEST CEIIII STREET FLYING J TRAVEL PLANA <br /> NO. SALT LMM, UT 84054 1501 N. JACK TENE ROAD <br /> Generator's Phone: 801 296-7700 Atta- RIPON CA 95366 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> ADAMS SERVICES, INC. (11139431 <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 /> DEMMOMEMIMM <br /> 2000 N_ ALMIEDA STREET CAT080013352 <br /> TON, CA 910222 <br /> Facility's Phone: 310 537-7100 DMI1 <br /> 98 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> '.NON—RCRtL HAZARDOUS WASTE LIQUID <br /> 0 (OIL Iii WATER) <br /> 1 TT 50 G 241 <br /> Z 2. <br /> w <br /> 0 - —--r <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1)99% WATER, 1% OIL <br /> AVOID EYE CONTACT z WAR RUBBER CLOVES <br /> CONTRACTOR. CHARLES E. THOMAS CO., INC. <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 EPAAcknowledgment of Consent. <br /> certi 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 /> G eratorsl0 eror's PrintedlTyped a Si re Month Day Year <br /> r� (, o L y o <br /> .J 16.International Shipme <br /> Import to U.S. Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signatur Month Day Year <br /> a 1.. CA r rF—L -01/ Z� <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> r <br /> V <br /> u- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Zz <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1' 2• 3• 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. UUUU1 DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />