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-- —--- ------ --—---- <br /> �' <br /> Please print o;type (Form designed for use on of e(12-pitch)typewriter.) FormAppreved WAS No.2050.0039 <br /> UNIFORM HAZARDOUS 11-Gerietato-IDNUmbe: 2.Page 1 0' 3 Emergency Response Phone7014058408 <br /> Manifest Tracking Number <br /> WASTE MANIFEST A L 0 0 0 2 5 8 2/ { 6 1 (800} 424-9300 JJK <br /> S. 11w am an•tta,i Ad s Genera:VsSite Admess(if0farantthar,maingaddress) <br /> ` �f. i �)�, T ,�i. RI E rrar. - vx ago: _ <br /> &16 FRONTAGE AD <br /> k1 YON CA 95366 <br /> GUC1 /5i—Llt;�> <br /> GeneralVs Phone: <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY NNVIRONNXNTAL SERVICES C A 1) 0 2 t? 2 7 7 0 3 6 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Dg q�a(CdF c ty N/mja�(,S�'ftgss U.S.EPA ID Numbe, <br /> l�p>�O la. AL41A�91MAV1STREET <br /> C4'.P i'ON CA 90:22 <br /> Fall! sPhone: (310) 537-7100 C A T 0 8 0 0 •t 3 3 5 2 <br /> ga 9b.U.S.DOT Descdpton Qnclud ng Proper Sn p, 9 Name,Hazard Class,ID Numner, 1L Conch net 11.Tota' '12.Unit <br /> HM and Packing Group(if ky)) F� `o Typ, Ouantty ?Wt Nd 13.Waste Code; <br /> trn loh4 n+acrrr fir.nuotnnr.rr y.rrnrTn nr n c nnn� nn•IA /? <br /> _, na.v u u ,.,uu..0 uu .•K i.•a ur .�. v.� � .�vu �.+v <br /> r� <br /> k(GASCrLiFIEi/UIisSELir �! G } S v <br /> a 2. <br /> w <br /> c� <br /> 1 <br /> 3. <br /> IV up.� <br /> E VI ON EIV AL <br /> Ht-AIT .nFPA TVP IT <br /> 14.Special Handling Instruct ons and Addr'uona'Information <br /> BN RC-rXY CO1xtT.ACT t =-ATRE'C 1-800-424-9300 NA RGQ 9B1 171 * PROFILE 0 9B). <br /> ;/070115-1 GASOLINE, DIESEL I•',I),TUF—'r t PO# A110211203 * kPPROP-MATE PERSOINAL <br /> PROTEr111VE F',)LlipmMir <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of th's coasgnmen,are f0y and accurately described above by the proper shipping name,argil are classfied,packageo, <br /> marked and labeledip%carded,and are in all respects in proper cond,Gon for transport accord, to aoplrable international and nat-val governmenta:regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this conslgnmenl conform to the terms of the attached EPA Ackrwm+'edgment of Ccnsent. <br /> the vra to in:: 'za !a n 'da n U CF 2' 27 d m a large qua nVy generator)o:(o)(if I am a s r,3'1 Quantity,gene true. <br /> Generalo er s rimed yped Na _ Signature Montn Day Yea, <br /> .—r 18.Int ational Shipments <br /> i— ❑Import to U.S ❑Export ham U.S Port of entglax t. <br /> Transporter signature(for exports only). Dale leaung U S. <br /> W 17.TransponerAcknowledgment of Receipt o!Materia's <br /> Trens her 1 Printed/Typed Name Signature Month Day Yea <br /> Z Iransoorfer 2 Printed yped Name "S'gnature Month Day Yea• <br /> Q <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indiubon Space d ^l ❑Res ue ❑Parva'Rtectlon Rejection <br /> ❑ Quantity Tyoe Full Re' <br /> Manifest Reference Number. <br /> 18b.Allernate Eacif.ty(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Faciivs Phone <br /> W 18c.SignalureofAJternaleFacilty(or Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management N!e!hod Codes(.e.,cedes fo:hazardous waste treatment,dsoosal,and recycDng systems) <br /> 1. O2 0 <. <br /> i <br /> 20.Designated Facility Ovmer o•Operator:Certification of rece'pt of hazardous materia's covered by the man fesl e -ncte�in Item 18a <br /> Printed? ed Name Month Day Year <br /> '� 7�L1 t� 9 <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. DESIGf4ATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />