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Please print or type_ Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Generator lD%urahpr 2 Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <Oa '34-9001 L ?3 yl I JJ K <br /> 5 Generator's Name and Nailing Address Generators Site Address(if different than mailing address) <br /> PAUL VAZ TRUCK*%*M!C <br /> 4740 E PELTIER <br /> ACAMPO, CA 95220 <br /> Generator's Pho ti,g 334-9001 <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> MIERICAN%%LLEY WASTE OIL, MVC <br /> 7 Transporter 2 Company Name tMU.S.EPA ID Number <br /> JRLUWIDE RECOVERY SYSTBft IWC CAR000175422 <br /> 8.Designated Faapty Name and Site Address A •*SFER FACILITY U.S.EPA ID Number <br /> AZR0W521W <br /> Facility's Phone&344-" <br /> ga 9b U S DOT Description(including Proper Shipping Name.Hazard Class,ID Number 10 Containers 11 Total 12 Unit <br /> HM and Packing Group(if any)) 13 Waste Codes <br /> No. Type Quantity WtNol. <br /> NON-RCRA I-IAZARDOUS WASTE SOLID,ABSORBENTS. WIPER OIL t 'FA 215 71 352- <br /> 0 F!;'r"Al f`FORIS <br /> a <br /> w <br /> z <br /> w <br /> c� <br /> 5 <br /> a <br /> 14 Special pfandling Instructions and Additional Information <br /> PROFILES 16M;t"RS PAPER FILTERS ERG#171 <br /> .UAFRGENCY CCMVTACT DF11 tE <br /> - r,Jo <br /> 5 GENERATOR'StOFFEROR'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 abeledrplazarded.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 tte contents of this consignm6kt conform to the terms of the attached EPA Acknowledgment of Cons t. <br /> I certify that the waste rlmimization stat0m"nt in 40 CFR 262 27(a)(if I am a large quantity generator)or ifl a small quantity generator)is true. <br /> Gener Offerors Pr4tediTyped NameSignature Month Day 'Year <br /> EIC ` A7,- tAtt7— <br /> 16 International Shipments <br /> F ❑Import to U S ❑Export from U S Port of entry/exit <br /> ? Transporter signature(for exoorts only). Date lea g U S. <br /> w 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 nted ped Name Signature Month Day fear <br /> a <br /> Z Transporter 2 Printedi iced Name nature M?i� Day Year <br /> 18 Discrepancy 1 �� <br /> 8a Discrepancy Indication Space ❑ Quantity ❑Type �\ Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b Alternate Facility(or Generator) U.S EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> C) <br /> N 19 Hazardous Waste Report Management Method Codes(i e codes for hazardous waste treatment,disposal.and recycling systems) <br /> 0 1 2 3 4 <br /> 20 Designated Facility Owne-or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnntedTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-1 Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />