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wr r <br /> Please.pdnt:or (Form designed for use on aide(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM`H&ARDOUS Generator Ip Number 2.Page 1 of 3:'Emergency Response Phone 4.Manifest Tracking Number <br /> a <br /> WASTE010 JJK <br /> :MANIFEST. C�tftC�a 2`31 j�3 ���-X71-5;�7 �'�. <br /> 5.GeneratoesName and Mailing Address Generator's Site Address(d different than mailing address) <br /> F?.AVIDS OIL CO.-5t",)CKTOV4 :615 iS3A JY <br /> Ptd WX 401 AT'f N:JOY,KAGHA O ` N <br /> W 'T SAGR i Crh. ::Ii :rcicropll;CIA T" ,3 <br /> Generatoes Phone a <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RFCMOS EMARt;.iNME—I*§rAL SERMOES INGC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> RAPW <br /> s Ef1ti e 7f>itsiEt�t1'. SER tTrE 1,10. <br /> 15'15 ZSOka Wi frit ix.•R ROD. GAL 2ct4W3Fr5l5 <br /> WEST SAC.-FAN.'---E-:PH01 GA 9;SC91 <br /> Facility's Phone:916-371-5747 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11,Total 12.Unit 13.Waste Codes <br /> HM and.PaddngGroup(dany)) No. Type Quantity WtJVol. <br /> 1 NON RCRA HPZARFJQUS, VVAa'C'E SCSI.B (OIL, DEBRtSs GD1 OI4 p :352 <br /> O <br /> F— <br /> 2. <br /> W <br /> r:9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> �� PRitF1E1fpdt5- r <br /> ERM-1 � <br /> 33At EXER5'.TO BE TRF IAO AIND.USE APPRNOVED PPE. <br /> E.R. CONTRA'R::1-WA ENVIRONMENTAL SERMCES <br /> 15. GENERATOIrS/OFFEROR'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 intemational 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 terns of the attached EPAAcknowledgment 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)('d I am a small quantity generator)is true. <br /> Generetoes/ roes Printedf typed Name SIg re 4 1. <br /> Month Day Year <br /> " �f <br /> -.r ..16.Int'eniati6nal hipmenls,_' <br /> F- ' ❑Import to U.S. ❑F�cportfrom U.S. Port ofentry/exih <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> Ce 17 jiansp*Admowledgment of Receipt or Materials <br /> Transporter 1 Printed/Typed Name Si ore Month Day Year <br /> a <br /> Kg- Tic &G -; <br /> Qransporler 2 FrnnWTypea Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity r <br /> ty ❑Type ❑Residue ❑Partial Rejection ❑Fult Rejection . <br /> Manifest Reference Number. . <br /> 18b.Alternate Facility(or Generator) U•S,EPA ID Number <br /> i;. <br /> 1,FadlIlys Phone: <br /> W.'•18c.Signature of Alternate Facility(or Generator) Montt Day Year <br /> 19:Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3,A . <br /> 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 /> Printed/Typed Name Sign Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. SIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />