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t or type. (Form designed for use an elite (12 -pitch) typewrilec) • FormApproved. OMB No. 2050-0039
<br />)RM HAZARDOUS 1. Generator 10 Number - 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number VES
<br />STM MANIFEST -i n r, r, r S t .. Ar ,n.- .a �,_;g,a� 000258623
<br />1A`=T- I`' EDUSTRiE'S SA _
<br />TPAIC f, CA 96304
<br />;tial Handling Instructions and Additional Information (,r DEBRIS 2) WATERIASPHALT 71- ER Servi, Ccentr2Gt2rd by VESTS
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<br />ENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, am are classified, packaged,
<br />arked and labeled/piacarded, 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 />xponer, I certify that the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent
<br />lertity that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or 0) ('dl amA small quantity generator) is true. n
<br />tar• O(feror's Pdntedityped Name
<br />Signature ' / Month Day Year
<br />*'jam /
<br />49 � n 'Ui A rn , E,. � `� ✓
<br />:mational Shipments ❑ Import to U.S. ❑ Export from Port of entry/ed
<br />_�. ---r..,, .,....,,nom —IIA. Date leaving U.S.;
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<br />orfar2PriRTTypedName QA
<br />sp'orter 2 Company Name - - U.S. EPA ID Number
<br />?GEONAND SON, lhsG. ': A C' 0 Q 4:7 7 8 ? 4
<br />grated Facility Name and Site Address. U.S. EPA ID Number
<br />VEGLIIA ES TECHNICAL SC UTIONS
<br />1704 VV. RRFT STREET
<br />X1,7 AZLIcA,'�: = 5170M r A. D u 0 a 3 Q t Q 3
<br />'s Phone: 8a^ v ,
<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />L Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />No.
<br />Type
<br />and Packing Group(dany))
<br />Quantity
<br />WtNol.
<br />❑Partial Refection El Full Rejection
<br />1NONEI NQN-F..CRA. HAZATRID JUS WA`1TE SQUID, (A -SPH ALT,
<br />Manifest Reference Number.
<br />'5
<br />U.S. EPA ID Number
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<br />;tial Handling Instructions and Additional Information (,r DEBRIS 2) WATERIASPHALT 71- ER Servi, Ccentr2Gt2rd by VESTS
<br />s
<br />ENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, am are classified, packaged,
<br />arked and labeled/piacarded, 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 />xponer, I certify that the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent
<br />lertity that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or 0) ('dl amA small quantity generator) is true. n
<br />tar• O(feror's Pdntedityped Name
<br />Signature ' / Month Day Year
<br />*'jam /
<br />49 � n 'Ui A rn , E,. � `� ✓
<br />:mational Shipments ❑ Import to U.S. ❑ Export from Port of entry/ed
<br />_�. ---r..,, .,....,,nom —IIA. Date leaving U.S.;
<br />h `i
<br />orfar2PriRTTypedName QA
<br />Signature
<br />- Montlr 'Day Year
<br />crepancy
<br />screpancy Indication Space ❑ Quaff
<br />- ❑Typa
<br />El Residue
<br />❑Partial Refection El Full Rejection
<br />Manifest Reference Number.
<br />U.S. EPA ID Number
<br />mmouss Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recyding systems)
<br />!4{ of 2. 3 4
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<br />,ignated Facility Owner or Operator. Cerbfication of repelp( of hazardous materials covered by the manifest except as noted in Item fee
<br />!typed Na, -
<br />Signature Month _, '� Month Da Yearr
<br />3700.22(Rei 3'05)'P'revio r
<br />editions are ob e . "' DESIGNATED FACILITY TO GENERATOR
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