Laserfiche WebLink
Please print or type. <br />I <br />Form Aonroved_ OMR No 9050-009R <br />EPA Form 8700-22 (Rev. 12-17) 'Previous e3itions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />1. Generator ID Number2. <br />Page 1 of <br />3. Emergency Response Phone . = <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />C A. L 0 0 0 3 3 4 4 3 <br />1 <br />(999) 999-9999 <br />017528374 FLET <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />FIRST_ EVTAGREEN OIL CORP FIRST EVERGREEN OIL CORP DBA PARKWOOD GAS & I <br />5500 QUASHNICK RD FOOD <br />STOCKTON, CA 95212 1.612 W H*'IMER -.LN <br />Stockton, CA 95209 <br />Generators Phone: (209) 482-2580 I <br />6. Transporter 1 Company Name _ U.S. EPA ID Number <br />BELSHIRE CAP.0 0 0 18 3 913 <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 />U.S. Ecology, Nevada operations. NETT 3 3 0 0 1 0 0 0 0 <br />Highway 95, 11 miles S. of Beatty <br />Beatty, NV 89003 (778),5-93-2203 <br />Facility's Phone: <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID.Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1' Non—RCRA Hazardous Waste, Solid (ERG 0171) <br />P <br />352 <br />*DO18 <br />Fo <br />(Rags, absorbent, & debris impacted with <br />petroleum hydrocarbons) <br />�M <br />)� <br />Z <br />2. <br />w <br />c7 <br />, <br />3. <br />4; <br />14. Special Handling Instructions and Additional Information please wear all personal $EST = 3 4 3 4 4 2 <br />Generator is a RCRA VSQG as defined in protective equipment <br />40 CFR 260.10. 110018 code represents required, <br />;waste that is RCRA identified but not " C <br />45S <br />~RCRA regulated. PROFILE,v.f 0702i4257-0 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I fiereby declare that the contents of this consighment`are fully and accurately described above by the -proper shipping name, arrd are classified, packaged, - <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifl am a small quantity generator) is true. <br />Generatoes/Offeror's Printed/Typed Name [ Signature Month Day Year <br />Q, Z1 <br />F <br />16.lnternat ipments <br />❑ Import to U.S.. ❑ Export from U.S. Port:of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />CL <br />Transporter 1nnted/Typed Name Signature Month Day Year <br />a <br />co <br />Transporter 2 Prin ed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy — <br />18a. Discrepancy Indication Space ty ❑ yP ❑ ` 1 ❑ 1 <br />❑ Quantity T e Residue Partial,Re'ection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />LL <br />Facility's Phone: <br />Ll <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />An19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />3. <br />4. <br />nated acility Owner or Operator: Certifcation of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />ped Name Signa re M nth Da ear <br />FP <br />EPA Form 8700-22 (Rev. 12-17) 'Previous e3itions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />