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DT & C. G4. -3 2. 21;y <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Farm Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emerganzy Response Phone :MO <br /> lfestTracking Numbef <br /> WASTE MANIFEST 800 -9300 17 46 7.67 0 JJK <br /> 5,Generator's Name and Mailing Address Generators Site Address(it ditferenl than mailing address) <br /> TRACY CHEVROLET-Q&M INC <br /> 3400 AUTO PLAZA WAY <br /> TRACY CA 95304 <br /> Generators Phone: 209 835-4500 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES LCAD028277036 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Faolily Name and Site Address U.S.SPA ID Number <br /> DEMENNO/KERDOON <br /> 2000 N. ALAMEDA STREET <br /> CGLlFI ON CA 90222 CRT 0 80013 3 5 2 <br /> Facility's Phone: (310)537-7200 <br /> ga. 9b.U.S.DOT Destriplion(Inducing Proper Shipping Name.Hazard Class,ID Number, 14.Containers 11.10181 12.Univ <br /> and Pa&n C13.Waste Codes <br /> mu d an Quantity HM 9 A t y}} No. Type bH Wti*l. <br /> 1 UN1993,WASTE FLAMMABLE LIQUID,N.O.S., (GASOLINE, DIESEL),3. QQQ1 U01 _14-1 <br /> �j� <br /> PG 11 <br /> Z 2. <br /> LU <br /> C9 <br /> 3, <br /> 4. <br /> 14.Spedal Handling Instructfonsand AcI tional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS NAERG#961:128 *PROFILE#981: <br /> 426350 GASOLINE.DIESEL* *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT ( q <br /> 13. GENERATOR'SIOFFEROR'S CERTIFICATION. I hereby declare that the conlents of this consignment are tuliy and acmralefy described above by the proper shipping name,and are dassiied,packaged, <br /> marked and labeledlplacarded,and aro in all respects in proper condition for transport accard+ng to applicable intemati D�ggnwemulations.If export shipment and I am the Primary <br /> Exporter,Icertify that the eonlenes or this consignment oordorm to the terms of the attached EPAArknoWedgment of Cccrfiry tltal the waste m' an statement identified in 4D CFR 2fi2.27(a)(rf I am a large quanffly generator)or bs true. <br /> ra�O nted7yyp Name A gn Month Day Year <br /> .J 18.Intemation i me <br /> i~ LJ Import to U.S. ❑upon from u.5. Pentrylexil: <br /> Transporter signature(far exhorts only): ate leaving U.S.: <br /> W 11.Transporter AcknoWedgrnentofReceipt ofMaterials. <br /> Tran r 1 Prin drType 1Name. Signature Month Day Year <br /> CL Aar u7 <br /> 1061 It 1 r <br /> 2C Transporter 2 PrinleffrTyWcfName Signature Month coy Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Cl Quam ❑Type ❑Residue ❑Partial Rejection <br /> ly Ful]Rejection <br /> Manifest Referenoe Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> J_ <br /> t.� <br /> U- facility's Phone: <br /> W 181.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> U) <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes tar hazardous waste treatment,disposal,and recycling Systems} <br /> C3 LLI 1. 2. I <br /> 4. <br /> 20 Designated Facility Owner or Operator=Certification of re*VQof hazardous materials covered by the manifest except as noted in <br /> Pri tedlfyped Name ySignature Month Day Yea <br /> Z <br /> EPA Foh 8700-22(Rev.3-05) Prokos editions are obsolete. DE NATER FkJLIfYTO DESTINATION STATE(IF REQUIRED) <br /> 1291 512 <br />