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Please it (Form for use 06 slits(12-pitch)typewd <br /> se Paidmor ly0e.(I Gain Form Approved.0M8 No.2050-0039 <br /> UNIFORM HAZARIJOUS 2'Pagelot 3.Emergency Response Phone P—Manifest—Tracking Number <br /> WASTE MANIFEST' --(S00)424-9300 011819,775 JJK <br /> Genamaes Name, Addressd Mallng Ad <br /> PICK N Puft'no ;1301101myaft Suvmcaress for current man mailing coolant <br /> 3927 CLARK DR. <br /> STOCKTO74 CA <br /> Gamerator's Phone 205462-1927 93205 <br /> 6.Transporter 70-Parry,Name— <br /> �WURY ENVIRONMENTAL SERVICES III II US.EFATIFN1�umb, <br /> T.Trans.porter 2 Company Name <br /> U.S.Epvf� 111277036 <br /> Numher <br /> B.Designated F <br /> 0 less <br /> DEME4I.EPA ID Number <br /> O/KER N <br /> 2000WALA MEDAS EET <br /> C�- 0222 <br /> COMPTON <br /> FaciliVsPhone: morJ53-1-7io'o- CAT0800i3362 <br /> ga. 9b.U.S.DOT Desumplion(Lticaft 1pi�O'Prvr ShIpPling Nam,Heard Clan,0 Numbef. <br /> Kill and Pealing Group(if any)) 1:Youal 12,Unit <br /> QuArdity, YVI 13.Waste Codes <br /> ar: <br /> 0 WASTE QASOI 3. Pa n 000i pois 3�3 <br /> 2 <br /> NON-�'HAZAqWIJS WASTE.LiQUID(BRAKE FLUID) <br /> OM 223 <br /> IdAcnlaamans <br /> 'Not} <br /> Nd� <br /> 13 Waste Codes <br /> 40—Conlainers Type <br /> D NI <br /> M-3 <br /> 000 <br /> 223 <br /> Q <br /> 3. <br /> 4. <br /> 7, <br /> W <br /> I(Igfpedhal Handing Instructions and Additional linforonaluori <br /> ?'a EMERGENCY CONTACT:CHEMM <br /> GASOLINE,9822 :367692 BRAKE FLUID PWAU004195ar APPROPRIATE PERSONAL FROTECITVtO&Mgkt <br /> 15. GENERATOR'WOFFEROR'SCERTiFICATION: I henebydeclane That greconteirls ofthis consignmenipm my and accurdelydescrind above by the properimistaing same,andarrodanded,packei <br /> marked and labeledIplimardled,and are In all respects In propercoodition for transport according to appliable internationsland national governmental regulations,Ifesciport shIpmentand I son the Pbi <br /> Exporl I codify[bat the contents of this consignment contorrin to the tons of the attached EPylAc6wledgenoril of Consent. <br /> I cedify(hat the waste minimization statement Identified in 40 CFR 262.27(a)Of I am a large quardly generator)or(bI am a small naturally generator)Is two, <br /> Garouldor'scoffemi's Pont yped Name <br /> I ., SignatureYearPay Y <br /> LUIS <br /> 18.international Shipments <br /> Ll EVIcutfirrimU.S. l` Poftofillitr&odt <br /> Trampoder signature if%uports oral Date Immi U.S.: a <br /> ar! 17.Transaction Acknowledgment <br /> of Reoldid of Materials <br /> O TransportsR anuffyisedNalosi Signisure <br /> Morth Da Year <br /> Ve) 13 <br /> z Tramplarter2i'didedilypeilli'liffse <br /> < ye) <br /> of Month Day. r <br /> 11 18.Discrepancy <br /> laa..Discrepancy Indication Sp.ace El Quarafy OTypre EIRbbas El Palo.,Rejeass, <br /> Full Rejection.' <br /> MariflostReferenc <br /> I So.ARemate Facility(or Generator) Reference Number: <br /> U.S.EPAID Mani <br /> w Fai Phone: <br /> 18c.glignalure ofAilennate Fertility(c,Generator) <br /> nth Day Year <br /> 19.Hazardo uayVarde Report Management Method Codes(IA.,codes fair hazardous waste freadment,disposal,no recycling systems) <br /> 4. <br /> J <br /> 20.DrabrialedFac9ty0werrorOperator.Certification ollecapto'hazardous materials covered by the marrifird exceI noted!in It hr <br /> jlf P:ff has ad,Nam <br /> Month III Year <br /> Forma 0022(Rev.3.05) Prevoinydildireare obsolete, <br /> DESIGNATED601L.rrym GENERATOR STATE(IF REQ,,! <br />