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Please print or type.(Form designed for use on ON (12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nu er 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Ct,L� 9e638 800.424-9300-CHEWME-c 0060 6 914 5 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> BRAW DIN TIRE-CLAREMONT 4605 CLAREMONT AVENUE <br /> P.O.W IX 24W STOCKTON,CA 65207 <br /> STOC ON,CA 65201 <br /> Generator's Phoney%e"!Sl..dfi? !R. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FREMOUW IRONMENfi-AL SERVICES INC. Phone*804551 3274 CAR000171017 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number• <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> EV R(iREEN OIL, INC. CAD OSS7418 <br /> 6M 3 SMITH AVE <br /> N ARK,CA 64560 <br /> Facility's Phone: 510-795-4400 <br /> ga 9b.U.S.DOT Description(including Proper S iipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) N( Type Quantity Wt.Nol. <br /> 1.. Nort-RCRA Hazardous Wast ,Liquid (Oily Water/Slu ) +7 i 1 + G 223 <br /> P <br /> Z 2. <br /> W <br /> 3. <br /> i <br /> 4. <br /> 14,Special Handling Instructions and Additional Inforrr ation <br /> HANDLERS TO'BE 40HR TRAI D AND WEAR PPE <br /> 9b1) ERCT#171 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately des hove the roper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all resl ects in proper condition for transport according to applicable intemabo al and onal go a ental r gulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consigr ment conform to the terms of the attached EPAAcknowledgment of C nsent <br /> I certify that the waste minimization statement id ntifed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b if I am small anti gener or)is true. <br /> Generator's/Offeroes Printed/Typedp�a�e_, , Signature Month Day Yea <br /> � � jW,7117d <br /> --r 16.International Shipments <br /> ❑Import to U S. ❑Export from U.S. PoRvf entry/exit: <br /> i=' Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Material <br /> �& Transporter 1 Printed/Typed Name / Signature — Month Day Year <br /> Ira !� ,12, 17 ter? <br /> QTransporter 2 PrintedrFyped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> - 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> ray- Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Co es(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. _ �/, 2. T— <br /> �4 <br /> 4. <br /> ' - <br /> 20.Designated Facility Owner or Operator:Certificatio of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prime d Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions ar obsolete. DESIGNATED FACILITY TO GENERATOR <br /> AA <br />