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i <br /> I <br /> Poease print or pe.(Form designed for use on elite(12-pitch)typewhii Form Approved.OMB No.2050-17039 <br /> UNIFORM HAZARDOUS 1.Cwwraar ID Number 2.Page 1 of 3.Emergency Response Phone A.Macking <br /> ri TaNumber <br /> WASTE MANIFEST C A n 008142661 JJ K - <br /> 1.Gen1N4YINIGRAPlEINOAM s Generators Site Address(ifdifferent than madding address) <br /> PO BOX 999 YYYY SS 2373 WRIPOSA ROAD <br /> LA PORTE TX 77572 STOCKTON CA 96206 <br /> Generators Prone: 9164U-3W I r <br /> 6.Transporter l Company NamaUC EA 14 p r2 8 2 7 7 0 3 6 <br /> ASBURY EN IRONNENTAL SERVICES <br /> 7.Transporter 2 Company Name <br /> U.S.EPA Number <br /> B.Des aced Fade Nadmeand SaAddress U.S.FPA ID Number <br /> S�IENENSryWATER TECHNOLOGIES CORP. <br /> 6375 SOUTH BOYLE AVENUE <br /> ..-... .....---LOS ANGELES..-..--... CA 90068 C.--AM_0 9 70-30-191.1-q <br /> Facie Phone: MM277-1600 <br /> 9b.U.S.DOTD , Inciudag Pr rShippois Name,Hazard Class,ID Number, 10.Conni 11,70tal IZ the ' <br /> 9a. sup hf an)) °pa Oumsty WLNoI 1A WaaM Codi <br /> HM end Packing Group(Iferry)) No. Typo - <br /> 7. <br /> r <br /> � 152 <br /> NON-RCRA HAZARDOUS WASTE, SOLID (OILY SOLIDS) C� .. M p <br /> w <br /> z 2. <br /> w <br /> C7 <br /> 3, <br /> 4. <br /> 14.Special Handing Instructions and Adddonel nlomlalion <br /> ENERGENCY CONTACT: CHEMfREC 1-800-424-93017 NAERGIII : 171'PRORLE#9B1 :AP181169 OILY SOLIDS, <br /> ABSORBENT, SWEEP`PO#Al 10134660-APPROPRIATE PERSONAL PROTECTAIF EOUIPNENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents oflhu consignmer8 am filly and accuratetydescrued shove by the proper shil name,and are classified,packaged, <br /> marked and labeledlplacarded,and are In all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment end I am the Primery <br /> Exporter,l certify that the contents of this consignment conform to the tens of the attached EPAAdmowledgment of Consent. <br /> I can*that the waste minmai statement Identified In 40 CFR 262.27(a)if I am a large quantity generator)or(b)(MI em a small oparri ganiiwli is Uue. <br /> Day e r <br /> Gene tors101femrs Prinad/fyped e <br /> L <br /> _j 11i Internagaal StigiiiiDImlwdto U.S Export from US Partaf entryle' ' <br /> Transporter signature(fa exports only): - Date leaving D.S.: <br /> W 17.Trensyxvl <br /> aterAclaxedgment of Receipt ofMatadalsour <br /> XT 7//Tra er i Pt ypad N Sign <br /> ' tue "7 yT <br /> O J <br /> a <br /> T spoder2 Pr dR ams grelure Monih Day Yeaz <br /> Disrrepal <br /> 18a.DlscWmcy Ind®tion Space ❑ Quantity ❑TYPe ❑Residue ❑PeNeI Rejection ❑FA Reledion <br /> Manifest Reference Number. <br /> 18b.Ahernale Facility(w Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W< Faul Phone: Monro Day Year <br /> W 18c.Sgndure Alternate Fadiy(or Generator) <br /> a <br /> z <br /> H19.Hazardous Wass Report Management Method Codes(I.e.,codes forhezeNous sass beabnent,disposal,and recydin9 systems) <br /> O 1. qbfi.W1'W <br /> 34.20.DazglaledFaGlNy r aratlecegt of hazardous scovemd by the manifest except as noted in item lB onlh DaY Year <br /> Name lure <br /> EPAFom18700.22(Rev.3-05) viouseditionsaleo el DESIGNATED FA ITY TO DES IN TION STATE (IF REQUIRED) <br />