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Please print or type.(Fofni designed for use on elite(12-pitch)typewriler.) Form Approved.ON No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator IDNumber 2.Page of lEmergency ResponsoPhono, 4.ManifostTrackingliumbet <br /> WASTE MANIFEST A I (Q 6 A 0 12 41.15 2.1- ".J" J K <br /> S.Generator's Name and Mal'nq Addfdss GrIninifoeiSMA 6si(if cWewt than nal;nq address) <br /> JIFFY Ltj;'JL#2""22 <br /> '500 E.KUTLUMM <br /> Genl2'(61911 Phone: C A 9 5 24 0 <br /> 6.TtanspoileflCompany Name- U.S.EPMO Number <br /> P7 <br /> 7.Tr <br /> U <br /> A,4�Nl,MipVy 01 2 3 2014 Akfi�- , <br /> Number <br /> 8.Des!qnaled I's0,ty Name and$10 Address U.S.EPA ID Number <br /> DK DIXON ENVIRONMENTAL HEALTH <br /> 7200 CHEVRON WAY DEPARTMENT <br /> Fa6l,qr5y".1. CA 915620 0 A T 0 r, 0 6 1 2 6 9 <br /> ga. 9b.U.S.DOT Descdpt;on(incIudAq Proper Sh:pp!nq Name,Hazard Class,ID Number, 10.CoMa'neis 11.Total 12,UrO 13.Wave Codes <br /> HM and Packing Group(d any)) No. Type Quantity VIIN61. <br /> 1. <br /> NMI-RCRA HAZARDOUS WASTE,LIQUID (OILY WATER) 0(,'1 1 TP C, 2 <br /> 0 -23 <br /> Jkk <br /> 3. <br /> 4. <br /> 14.Specla)Handing lnsUutConsar.dAdd:riDnalinfofniaCon <br /> MAEROft 981: 171;Y PROFILE ft 921: DK110442 1:E1'1,iL-'RGGXY CONTACT;CREMTREC 1-800-424-9300 <br /> ADDI-flONALFPA("'ODF--8 :9BI' , NOt4l: xAPPROI)RIA'fFPFRsOt4ALPROTECTIVE EQUIP&IENT <br /> 15. GEtIERATOR'VOFFEROR'SCERTIFICATIO?I: I hereby declare that the contents of this cons.1goment are tutly and accufatefy described above by the proper sh!pN name,ard are cfassZtd,packaged, <br /> narked and laWapl.acafdod,and are in art respects In ptope(cond-Con for transport accordling to apftallo intemaVonal and naVonal governmental reg Cons.if export A!pmem and I am the Primary <br /> (Porter'I cet6ftr that the contents of INS cons!,gnmenl conform to the term of the attached EPA AckwMedgment of Consent. <br /> I c"thatthe haste MWOa�-onsta�maritidenffied MO CFR 262.27(a)(f I am a large quantity qeQVatot)of(b)Awn a sma!IqdnAgWerata)is two. <br /> on A 0 rot p S:..g Month Day Year <br /> P,>I -L <br /> VI <br /> -j 16.hileriaonat Sh'Nrri6ts ❑Import to U.S. E]Export from U.S. Port of entrwey;t: 0 <br /> Transporter signature(for exports on'y): Date leaV.ng U.S.: <br /> 17.Tf anspodef AckwMedgmeni of ReceV of Material; <br /> Transporter Month Day Year <br /> JA;1P;'tedrr ped Name S.tnalum <br /> y A 1,0 1 <br /> -le- Montli Day Year <br /> 2Transporter 2 Printed/Typed Name S..'griatufa, <br /> R <br /> 18.Discrepancy <br /> 18a.Discrepancy(n&cafion Space Quantity []Type ❑ResVuo ❑Partial Relec6on ❑F.'1 Resection <br /> Manifest Reference Number; <br /> 18b.Memato Fac,!.V(or Genefa'M) U.S.EPAID Number <br /> zi <br /> 0 <br /> cc I <br /> u- Fao5ys Phwo: Month Day Year <br /> 18C.St natura 01 Alta Inate Facility(of Generator) <br /> 19.He za tdous WaVa Report Ma nag a n-w nt Method Codas(I.a-,codas for haza idout wa sla treatment,disposal, recycling Systems) 14. <br /> 3. <br /> LAJ 1. 2. <br /> 20.Dis*ated facility 0&ner or Operator.CeilificaUon of tecelptolhazardous materia!'s covered by the manifest except aInded in Item 18a <br /> Prim'f mon_tkl Day at <br /> ped Name <br /> COOL)Ft�� <br /> E i'Fotm 8700-22(Rev.3.05) Pieviours.editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE (11REQUIRED) <br />