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016869922JJK <br /> Please print or type,(Form designed for use on elite 12-pitch typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.General"'ID Number 2.Page 1 of 3.Ernnenhcy Response Phone 4."aMfeetTr mWV Number <br /> WASTE MANIFEST CAL 0 0 0 3 7 7 5 5 2 1 (800)424-9 016869922 JJ K <br /> 5.Gerhena4Ys Name and Mailing Address Generators Site Address(d different than mailing addra m) <br /> TRACY VW INC DBA TRACY VOLKSWAGEN <br /> 2266 KUrINAWK ROAD <br /> LIVERMORE CA 94551 2605 AUTO PLAZA WAY <br /> Gerheratcrs Phone 209 407-1061 TRACY CA 95304 <br /> 6.Trarhaoorler 1 Company Name U.S.EPA ID Numb` <br /> ASBURY ENVIRONMENTAL SERVICES C A 0 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> 8.Desgreted Facility Name and Site Address U.S.EPA ID Number <br /> US EOOLDGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br /> Fao6lys Phone: 323)277-lW <br /> 9a. 9b.U S.DOT Description(induding Proper Stepping Name,Hazard Class.ID Number, 10.Containers 11.TOW 12,Unit 13.Waste Codas <br /> HM and Pacidng Croup Of arty}) No. Type Quantity M4N01. <br /> rx I NON-RM HAZARDOUS WASTE,SOLID,(OILY PAPER FILTERS) <br /> 0 352 <br /> D Q P <br /> w <br /> W 2 <br /> L5 <br /> 3. <br /> :,el <br /> EI W NJE I:AL. IE;Allll <br /> 1)l <br /> pA It E 7 1 <br /> 11.Special Nandung+r>,slnlrf)orms and Additional Irdormeton 10,i,0 16 <br /> EMERGENCY CONTACT:CHEMTREC 1-804424-9300 NAERGO 961;171 "PROFILE N 981:P209259 OILY PAPER FILTERS� <br /> P5004)0034245*APPROPWATE PERSONAL PROTECTIVE EQUIPMENT 1)(55- <br /> XSS1516. <br /> . GENERATOWSIOFFEROWS CERTIFICATION:t hereby declare that the contents at the mnsigmmerd are fury and accurately descrbed above by ehe proper shlppahg name,and are daeai Ted,padaged, <br /> nwked 0.M labelad"arded,and are in all respects in proper condition M transport according to applicable Irhtemational and national governmental regulations.9 export shipment and 1 am the Ninary <br /> Exporter,I Call that he contents of I'm consignment conform to the term~of the attached EPAAdmooiedgmaM of Consent. <br /> I cortily tat to waste mnim¢ellon t:Ntemenl laentltied in 40 CFR 252.27(a)(if I am a large Quantity genera (b)(dl am a small quantity generator)h true. <br /> Gamnillikit'Oftroes PrintedrTyped Na SgnaLt .94 Month Day Year <br /> XjV0RAAJCC 124 112- 11-7 <br /> J 16.Intanhational Shipman4 <br /> F ❑import to U S. ❑Export from U.S. Port of erhbylexit: <br /> Z <br /> Transporter sitlinaturs(for exports only)* Date leaving U.S.: <br /> W 17.Transearlx mo <br /> Adcwledgrnanl of Receipt of Materials <br /> T 1 PrintednrypedName Sign Month Day Year <br /> g 2�e <br /> Tran 2 PiiraedlTyped Name S-gnatiue Month Day Yaw <br /> 16.Discrepancy <br /> 180..Discrepency lnditalion Space <br /> Ot®rnaty ❑Type 1:1 Residua El Partial Rapmm ❑Full Rejection <br /> Manifest Reference Number <br /> 180,Ahenhate Faddy(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faaliys Phone. <br /> W18c,Sgrhature of Arwnate Facility(or General" Month Dsy yew <br /> Q <br /> Z <br /> a* 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and rhlcycling systems; <br /> Uj G 1' 2. 3. 4. <br /> 20.Desi ni Feal y Owner or Operator CertAcew o1 receipt of harardous matenats covered by the manliest except as need n Item tea <br /> 'nted/7yped Name - 1 Signature Month Day Year <br /> 1 c K(;Q. k 0k � <br /> EPA Fenn 8700.22(Rev 305) Previous editions are obsolete. DESIGNATED FACIL DESTINATION STATE(IF REQUIRED) <br />