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Please print or type. «. Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. ManHost Trach N�umbar q <br /> WASTE MANIFEST CAL 0 0 0 4 2 9 8 4 7 i { 925 ) 7 $ 5 -2000 1 p y, W � J FLE <br /> S. Generator's Name and Mailing Address Generatoes Site Address (it different than mailing address) <br /> AMBIT SANDHU CAGbSOLINE INC DHA CAGASOLINE EXPRESS <br /> 2115 WEST YOSEMITE AVE 2115 W . Yosemite Ave . <br /> MANTECA, CA 95337 Manteca , CA 95337 <br /> Generatotsfhone: 925 785 - 2000 <br /> 6, Transporter 1 Company Name U.S. EPA ID Number <br /> BELSHIRE @AR0001839L3 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number ' <br /> 8. DestgnaWf1Wlily Na-M-e and Site Address -- -- - - - - — _ — - — — — -US:EPA IDNUffi C <br /> U . S . Ecology , Nevada Operations 19VT 3 3 0 010 0 0 0 <br /> Highway 95 , 11 miles S . of Beatty <br /> ILi t NV 59003 ( 775 ) 553 - 2203 <br /> F. r a ho , <br /> NEVA <br /> ga• 9b. U.S. DOT Description (mciuding ProperShipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (ff any)) No. Type Quantity MJVoI. <br /> 0 1 ' Non-•RCRA Hazardous Waste , Solid ( ERG 0171 ) P 352 *DO18 <br /> ( Rags , absorbent , & debris impacted with <br /> petroleum hydrocarbons ) 2 � M Zclrj <br /> z 2. <br /> W <br /> G7 <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information PLEASE WEAR ALL BES I ; 3 3 3 8 2 8 <br /> Generator is a RCRA VS12G as defined in APPROPRIATE PERSO24AL <br /> 40 CYR 250 . 10 . D018 code represents PROTECTIVE ROUIPKKNT <br /> waste that is RCRA identified but not PROFILE 070214257 - 0RCRA regulated . <br /> IXES <br /> 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, <br /> marked and labeled/placarded, and are In all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and 1 am the Primary w <br /> 'Sporte7, f zwr% 0iaf the contents of tfiis consignment conform to the terms of the attached-EFAAskriowiedgment of Consent - — — <br /> I ce* that the waste minim¢ation statement identified in 40 CFR 26227(a) (ff I am a large quantity generator) or (b) (ill am a small quantity generator) is true. <br /> Generator's/Offerors Pdnted/Typed Name ) Signature J - Month Day Year <br /> 16. International Shipments <br /> ❑ import to U.S. ❑ Export from U.S. Port of enlrylexit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printefir <br /> Name Signature Month Day Year <br /> a <br /> QTransporter 2 Printedrryped Name Signature Month Day Year <br /> 18, Discrepancy <br /> 18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. VON <br /> 18b, Alternate F'adrdy (or Generator) U.S. EPA ID Number <br /> J <br /> Cy <br /> LC Facilhy's Phone: <br /> 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> 4 <br /> Z <br /> _ .— y 9rHazardous�Yaste-Report.Management-Method Codes (ie. codes for-hazardous waste trealmen4 dispesat-andiegc1mq systems) - — — - — — <br /> C 1 . 2. 3. 149 <br /> 20. Deslg ted Facility ery Operator. Certification of receipt of hazardous materials covered by the manifest except as nded irykem lbq <br /> PrintedfTyped Name Signature �Qggjh Dqy Y�a� <br /> EPA Form 870022 (Rev. - 7) Previous editions are obsolete. DESIGNATED FACILITY(,JYT'I`0 GE tNI �ERAL/TOR <br />