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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 Trackln Number <br /> CALO3 WASTE MANIFESTT <br /> fl4 GBF <br /> 5. Generator's Name and Mailing Address <br /> s S A r f I r t ilin ddress) <br /> <im VQ1Jtftwiw Cr , . MA,441'ECA <br /> 3111 8IlA) ?I (:St0J) A'VI <br /> ��Ar�` IR A, OA '951ag AR 0 2 2016 <br /> Generator's Phone: 2..Ot3-:i2$-J i - � OFi <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> AIVIE111(444 VALLEY WA�A`Lq OIL, ilk;.:: AL ti ALt}W827i 78 <br /> 7. Transporter 2 Company Name H��TH DFPAIR�T"17( EPA ID Number <br /> it ' It ' r8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> i if " +ky�,:Eh� fppj�,U�fftt{;`Y)`yy+tt+t}wti <br /> gO! MENTAT, Ad:: 461 01F NEVADAJ41; 1 1 flPretfi3` <br /> II 1JO* <br /> Facility's Phone: :''P5 <br /> ga. 9b4 <br /> 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 (tf any)) , . . No. TYPe Quantity Wt Nol. <br /> 1 ' # 3cJt h*CRI� t Afil9c N b5 ' tA, 3'I' WOE) / ' *4 P2ciX <br /> 0 A€ S1 0RISOTT1 OIL <br /> w 2 <br /> O <br /> 3. - <br /> 1 <br /> i <br /> 4 <br /> IV I <br /> 1 - <br /> 14. Special Handling InsWc 'onsa ddibonal lnformaUon , <br /> tF <br /> 1 Ea O"Y CONTACT IVINno DAY <br /> , : . <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper <br /> d cka <br /> 1 shipping name and are cI ss fie , a aged, <br /> SPP 9 a .� PIF <br /> W'O <br /> marked and labeledlplacardedIII r <br /> anti are in alfrespects in proper condition for transport aeeording to applicable International and national governmental regulations If export shipment and I am the Primary <br /> Exporair I certify that contents'of this consighri conform to the terms of the.attachetl EPAAcknowledg"inept of it <br /> " <br /> ty in 40 CFR 262,27(a) (if I sm`a large quantity generaio�) or (b) (ifl 'am a small 'quantity'generafor) is flits: <br /> " ! certi that tie wasteinimmrzaUon`statement idenUfietl <br /> Generaiosl0tferoisPnntedlTypeoNanti FIt IF ' Signature r r } LIr Month r DayI IF <br /> �Mear <br /> OF <br /> ri <br /> .; .. _ <br /> 16. International Shipments v ` " <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> Date leaving U <br /> I OFF Transporter signature (for exports only):= _ - — — - -- <br /> W pi <br /> 17, TransporterAcknowl ' gment of Receipt of Materials <br /> Month Day Year <br /> Transported PrintedlT fed Name Signature ff f , , <br /> O 1 R , . <br /> CL inommona 1 t + M }' Month D ,Y. Year <br /> { za Transporter 2 PnntedlTyped Na e: Signature -� <br /> Hit <br /> I . Fitt III OL Fit ; I <br /> It <br /> 18. Discrepancy -� <br /> Fills. Discrepancy Indication Space quantity ❑ TypeIt Ft ❑ Residue Partial Refection ❑ Full, I I It JLRejection <br /> a 4, <br /> { Manifest Reference Number. PA <br /> 18b. Alternate Facility (or Generator) LL i! * IU S. EPA ID Number <br /> Mj i - IF <br /> - <br /> Facility's Phone: <br /> W 18c. Signature of Alternate Faeilily (or Generator) <br /> Month ay <br /> Z It <br /> Q) 19. Hazardous Waste Report Management MethodCodes (i.e., codesfortiazardouswastetreaiment, disposal, ,andrecyclingsystems) Notice : State - of California requires <br /> LU <br /> ,1 z. . . 13* gernerator to photocopy and mail to <br /> ' . DTSC with 30 days : <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18aOFF <br /> ' P . O Box 400 <br /> %Prinled/ryped Name Signature <br /> E Sacramento, Ca 95812-0400 <br /> 4 EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. <br /> ,.;;. GENERATOR'S INITIAL COPY <br />