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�.:-. ............ <br /> � u <br /> Please printor type,(Form desired forum on elitel2-pitch)VIevrtitec) Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS 1.GenwalcrlDNurnber 2.Pagetof 3,Emergency Response Phone 4.Manlfest Tracking Number <br /> WASTE MANIFEST C n D 9 6 2 3 5 6 9 4 1 90 424-�'33ga 0 0 9 573266 J J K <br /> 5.Generator's Name and MailhgAddress Generetors SHeAddr (pdigerentcanmeingaddress) , <br /> MAXIM CRANE WORKS <br /> PO BOX 999 2373 WRIPOSA ROAD <br /> LAPORT E TX MM TOCKTON CA 95206 <br /> Genarerola Phone: 916 452-3961 <br /> 6.Transporter 1 Company Name U.S.EPAID Number <br /> ASBURY ENVIRONivENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name - U.S.FPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SIENENSINDUSTRY. INC. <br /> 5375-SOUTH BOYLE AVENUE.... .... <br /> LOS ANGELES CA 90058 _...... --._-.__._... _ . ... . _._. C A D 0 9 7 0 3 0 9 9 3 <br /> F aPh"; (323)277-1WO <br /> f <br /> ga. lib.U.S.DOT Description(including Proper Snipping Nacre,Hazard Close,ID Number. 10.Containers 11.Total 12.Unit 13.Waste <br /> HM aWPacldng Gmupihfany)) No. Type Quantity WtNd. <br /> 1. <br /> NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) Z L7 vt by G <br /> W 2. <br /> r, <br /> E <br /> 3. <br /> f <br /> 4' If <br /> rk <br /> 14.Special Harding Instructions and Addlhonal Information y. t <br /> ENERGENCYCONTACT: CHEMIIREC 1-900-424-9300NAERG#9B4 : 171 'PRORLE#9B1 :AP481159OiLYSQ bse; I <br /> ABSORBENT,SWEEP'PO#A110161163'APPROPRIATE PERSONAL PROTECTIVE EOUIP T <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment we fully and accurately described above by the proper enroll rens,and are ciessiled,packaged, - <br /> marked and labeled/placarded,and are In all real in proper condiilon for ovaport aowrdhrg W applicable Internet"and national gwemmenlal regulations.If export shi ment and I em the Pdmary <br /> E Voter,I certify,that the=tents of this wnelgnment conform to the terra of the attached EPAAdmawledgmerd of Consent <br /> I certlty Uat the waste ninlmtratton statement Identilad N 40 CFR 262.27(a)If I am a large quantity generator)or(b)(d I am a sinal quantity generator)Is true. <br /> rem sr Offerors Pdntedrrype ama Si lure rrm_. Days YB I <br /> � 0A S `/ <br /> ..l 16.International Shipmenu <br /> F ❑Import to U.S. ❑Export from US. Port of eney/exit: <br /> Z Tmnsportersignature(for exports only). Data leavng U.S <br /> ITTrempoterAchr mledgmenl W Rao*of Malaria's <br /> T 1 Printad(T ed Name Sgna n De Year - <br /> G/> -One1 <br /> za Transporter 2 PrinteeLV Name Signal Month Day Year <br /> } 16.Discrepancy <br /> 1Sa Discrepancy Indication Space ❑ Qrsnbity ❑Type ❑Realdue ❑Partial Relectbn ❑Full Rejection <br /> Manifest Reference Number. <br /> 16b.A temaie Pacerty(or Gonomtor) U.S.EPA ID Nurn w <br /> 7 <br /> V <br /> LL FadGlys Phone: <br /> W 16a 6gnwure of Mamate Facility(or Generator) Mone. Day year <br /> X <br /> y19.Hazardous ste Report Management MMMd diodes(Ice.,ads for hazardous wade treatment,disposal,and mrydng systems) <br /> 1. 2. 3. 4. <br /> 20,Designated Ncfltyr or Oper .tor.Certification of recelpl of h lariats cove4 by the manifest except as noted In Item 1 1441 <br /> Prin yped Name gnature Month Day ear <br /> EPAFortn3700.22(Rev.3-05) W sedifimsareobsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />