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Please print or type . (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050.0039 UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, ManifestTrack791344 n Number WASTE MANIFEST A L 0 �: 0 a r, �> ( � , , : ; v 017 7 913 4 4 JJ K 5. 'Generator's Name and Mailing Address Ganaralor's Site Address (if different than malting address) r Liv1111 ? GHIl YSLER DO ' GF '1,-' P i , AiM OF i RACY - PRFA' 11 i 3 0` 0 Nr;<) LEE RC,AD I I �1tA; f CA 56 : 0 # 9 Generator's Phone: V � 5 :� 0- ..i. b .1. J 6, Transporter 1 Company Name U.S. EPA ID Number ASS URT' ENViRONNIENTAL SERVICES CAD 0 2 5 ? 7 r O 3 6 7, Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U .S. EPA ID Number DEIVtiFill N I f I% EAR070H 2000 N . ALAM EDA STREET COMPT01' I CA 9ii2 'l' 2 C A T l ) L1 0 1 3 3 5 f Facllity'sPhone: ( :i. f }j,` 37 - 7 :1.00 ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity WLA1011 1 UN1993 WASTE FLAMMABLE LIQUID , N . O .S . , (GASOLINE , DIESEL, _ D001 ! D0143 ' ,4 :3 0 4ATEP, ) , 3 . PG 11 D 6A � C LU 2. 3. f 4. i 14. Special Handling Instructions and Additional Information EMERGENCY CONTACT : CHEMTREC 1-800-424- 9300 WOES TERMINAL : CERES CS PROFILE # 961 : 042717 -01 GASOLINE , DIESEL , WATER * * APPROPRIATE PERSONAL. PROTECTIVE EQUIPMENT ' y 15. GENERATOR'SfOFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of onsent. I cortify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity ge _ tor) or ) ill am a small quantity generator) is true. Gen t stOfte r s Printed/TypeQ arae ignal a Manll , Day Year .a 16. InTUnAtional Sbipmeflis r� ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials a Transporter Printed/Typed NamoAr Jgnature / Monti h- Qay CIL i l is , * iPW& 19 QTransporter 2 Pdnted/Typed Name Signature Month Day Year 18, Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residuej El Full Rejection ❑ Partial Reaction Manifest Reference Number: 181b. Alternate Facility (or Generator) U.S. EPA ID Number J V LL Facility's Phone: w 18c. Signature ofAlternate Facility (or Generator) Month Day Year Q 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 1 , 2. T- 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnledrryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FAGILITYTO DESTINATION STATE ( 1F REQUIRED)