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DTSC 4284:-063,1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'Generator ID Number 2.Page1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 5118 3 1 (800)424-9300 016774046 J J K <br /> 5.Generator's Name and Maili Address Generator's Site Address(d different than mailing address) <br /> TRACY FORD MERCURY <br /> 3500 AUTO PLAZA WAY <br /> TRACY CA 95304 <br /> Generators Phone: 209 835 4821 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Des DEMENyNO/KERDOON U.S.AddEPA ID Number <br /> 2000 N.ALAMEDA STREET <br /> COMPTON CA 90222 <br /> CAT 0 8 0 013 3 5 2 <br /> Facilitys Phone: (310)537-7100 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity WtNol. <br /> 1. NA1993,COMBUSTIBLE LIQUID, N.O.S.,(DIESEL),PG III 223 <br /> 0 <br /> DM G <br /> z 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 NAERG#9131:128 *PROFILE#981:353868 DIESEL * *APPROPRIATE <br /> PERSONAL PROTECTIVE EQUIPMENT � -2 , �4 -- <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratey described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respells in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it l am a small quantity generator)is fru <br /> Koes/0111VAes.9interyped Nam Zre Month Day Year <br /> zt��y <br /> J 16.International Shipments <br /> F— 11 Import to U.S. ❑Export from U.S. Port of entry/exi <br /> Transporter signature(fore rts only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T iter 1 Prin drT ed Name Signature Month Day Year <br /> 0 4 <br /> Qcr <br /> Transporter 2 Print ed Name Signature Month Day Year <br /> t` <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> 0 <br /> I Facility's Phone: <br /> 93 LU <br /> Signature of Alternate Facility(or Generator) Month Day Year <br /> t— <br /> Q <br /> Z <br /> CD19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> oro 1 1�23q <br /> 2. <br /> 1 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 <br /> Prin yped Name Month Day Year <br /> OIAV la V0Z <br /> Form (Rev.3-05) Previous ed ' areobsoee. DESIGNATE FACILIT1/TO DESTINATION STATE(IF REQUIRED) <br /> 12686.2067 <br />