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Please puff or type:(Form,designed for use on elite,(12-pitch)typewriter,) Form Approved.OMB No.2050-0039 <br /> IFS RDOUS' 1.Generator ID Number s 2.Page 1 of 3, m R s o se P 4.Manifest Tracking Number <br /> M�,NIEST '� g <br /> "X(qiihno-ft Name and Mailing Address SKS <br /> . <br /> ESA . D '` Generator's SiteAddress(if different than mailing address) <br /> 8501 OS — O fd D <br /> St ufavd d Attu Samuel eery 16501 Stanford Rd <br /> f ..ro CA ` 5377 Atte safety Sam <br /> Generators Phone:. aa � 39 ��+ � <br /> 1-JM ff 6_n # 95377-9708 <br /> V TE B .INC U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address BA <br /> +' ( ( y(4 (� t U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK CA 94360 <br /> P -795-4400 <br /> Faciliiys Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10Containers <br /> HM and Packing Group(if any)) . 11.Total 12.Unit t3,Waste Codes", <br /> No. Type Quantity Wt./vol. <br /> (USED OIL) TT 51 eat , <br /> opt <br /> z 2,' <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information T 8 fj <br /> CBS. <br /> 4 R EMERGENCY 01-NO-468-1760 (SK / ` FI) <br /> ' CARRIERS AS <br /> 15. `"GENERATOR'S/OFFEROR'S CERTIFICATION+: Ihereby declare tithe contents of this consignment arse fully and accurately described above bey CESSARY the proper shippingBEN LICENSED 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 /> Generatorsi0fferors PrintedTTyped Name Signature Month Day Year <br /> + A4r>�� , r;,, <br /> .-I 16.Internafionai Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.! <br /> % 17,TransporterAcknowledgment of Receipt of Materials <br /> O T ns orter 1 PrintedTrI yped NaTe gnature <br /> ( Month' Day = Year <br /> TV Printed/ <br /> C <br /> Q ransporter Printed/Type ame Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> 4 <br /> _gZ Manifest Reference Number:18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q I Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1• <br /> f 2• 3 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nctab in Item 18a <br /> Printedfryped Name Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous e8itare obsglete. ��'� X' DESIGNATED FACILITY TO GENERATOR <br /> ) i ,r, r''P r tt�t{1 Q f / ` <br /> liY,,c/ <br />