Laserfiche WebLink
..fir.:i•!f`''"�a -. _ <br /> Please print or type.(Form designed for use on e1(12-pitch)typewriter.) Form Approved.OM8 No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Nu'mbe: 2.Page 1 or 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST A .L 0 0 0 2 5 £1 2, 3 h : 1 0140 5 8408 JJK <br /> 5. �lor' am and.A:a i Add ss GeneraWs Site Address(if diffarent than mail ng a5dress) <br /> VAN60 ' <br /> tl , 2 FRONT1,GE AD <br /> k1.Puiv �•k yb3Ge� <br /> •LU 1 <br /> GeneratVs Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASSBURY ENVIRON-MENTAL SERVICES iC A 0 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.D 4i4 1 <br /> 1#61 NymIaud S06dd[ess U.S.EPA ID Number <br /> 7000 14, AI,AMr--DA STREET <br /> i:Cr;4P t ON CA 90222 C: A T 0 8 O G 1 3 3 5 2 <br /> Facility's Phone: (310) 537-7100 <br /> ga 9b.U.S.DOT Description[nclud ng Proper Shipp g Name,Hazard Class,ID Number, 10.Conla hers 11.Tota: a 12.Unit 13.Waste Codes <br /> HM and Packing Group(if 9hy)) r No. Type Quantity Twi'Qo1, <br /> 1t11*14hj LrnCn'1T 1RT.zIfDAnRT:N T."rnttTn h1 n.c hfl(11 r�rliR A? <br /> _r na.u.0 i ,..uu wu_u� u..•X�>ur �� v,r "r" �'"�'� "' <br /> (GAS-0-1 1NEi/UI;::SEL} � �� l G X G <br /> z 2. <br /> LU <br /> CD <br /> 3. <br /> r <br /> 1 - <br /> 14.Special Handling Instruchons and Additional Information <br /> FM RC--ETdCY CONTACT i =.4TREC 1-800-424-9300 iQAERG$ 9B1 171 * PROFILE 9B3. - <br /> Qtb 15-1 GASOLINE, DIESEL I-1I)%TUPW k PO¢ A110211203 t APPROP�'_IATE PrRS03YAL <br /> PRU' ,cr11rB' F;�uII*LhT ,!,/ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignmenTare fully and accurately descdbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlp!acarded,and are in ali iespecls in proper cond tion for transport according to applicable in:emationaiand national govemmenlal regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA AckmVedgmenl of Consent. <br /> I the vn le ini 'za la n'de n 0 CF 2 27 if m a large quantity generator)o:(b)(if I am a smali quantity gens true. <br /> Generato,WeWs dnted ypedNa - Signature Arai Month Day Yea <br /> —r 16.Ince ational Shipments <br /> IL- ❑Import to U.S. ❑Export from U.S. Pod of enlry'exl.. <br /> z Transporter signature(for exports only). Dale leaving U.S.: <br /> IX 17.TransportarAcknowtedgment of Receipt of Materials <br /> Trans iter 1 PdntediTyped Name S!gnature Month Day Yea, <br /> alransporfer 2 PrintedrTyped Name Signature Month Day Year <br /> 18.Discrepancy - - <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue ❑partial Resection ❑Full Rejection <br /> Manifest Reference Number. i <br /> 18b.Alternate Facility(or Generator} U.S.EPA ID Number <br /> _J <br /> V - <br /> LL FaclliVs Phone: Month Day Year <br /> Qw 18c.SignalursofAllernateFacility(orGenerator) <br /> z <br /> S2 19.Hazardous Wasle Report Management Method Codes(i.e.,codes fo:hazardous waste treatment,disposal,and recycling systems) ; <br /> coo 1 2 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest a "ncfec in Item I Be <br /> Printedrfyped Name Signa re Month Day Year <br /> O f <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, DESI ATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />