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-----__._.--- -- - REC'D JUL 16 2015 <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.Page 1 of 3.Eme gency Response Phone 4.Nlan'rfest Tracking Number <br /> WASTE MANIFEST .Q ► pry, a?w� 013082920 JJ K <br /> 44 L 0 Y V 2k k� J 3'`1 i. 1{F Y+Y.'!4tev-a•.esr <br /> 5.Ge tato' a Generator's Site Address(d different than mailing address) <br /> ` � �y4{ ' - ` ¢RAC:O� WE <br /> G � _ E? <br /> PC" 90ft'e'YWtsw9'Y r p, F' T �r Grit�•tJL�iS tiii3iCE s.n P�'/�t�` <br /> f-i.4 Astgaea yah ��� F i fCf!� u`i asi106 <br /> f0VKrLha <br /> Generators Phone: a ' "Z2 1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number _ <br /> As'-BURY EWIRONMENTAL SERVICES <br /> 036 <br /> 7:.;Transporter 2 Company Name U.S.EPA ID Number <br /> BDesi4.aatddac�l�y U.S.EPA ID Number <br /> 9WRO'LOGIES LLC <br /> 5375 sSt;A€,'T'ri BO`s AVENUE <br /> LJ ANGELES __ _ s '�� 4 4 9 9-a <br /> k800)256-i f 4 F <br /> Facditys Phone:. <br /> gy 9b.U.5.DOTDescription(including Proper Shipping Name,Hazard Class,iD Number, 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Pecking Group(if any)) _ No. Type Quantity Wl <br /> 1. Wj - HAZARDOUS WASTE,SJR (OILY Ei � D t" a5 � { <br /> a 2 <br /> 1 <br /> LJ t <br /> t9 <br /> i <br /> ! <br /> 3. ) <br /> 1 <br /> 4• I I <br /> F 1 <br /> i � I <br /> 14.Special Handling Instruct ons and Additional lniormation JU <br /> tEc9Ei:171 * r=riQ-LE :f+r is~; i bEF EeEti 4�t�T �T:vNE..i i4E.�f - 00-4� r f <br /> fl 4SEO?- ` RLITIf� E� C l NON' <br /> eF [` IrS _ <br /> 6l= <br /> EGIJ€f"i�EEEhi � 07,01q <br /> .. a� o_- <br /> 15 'GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeiedlplacarded,and are in all respects In proper condition fur transport according to applicable intemational and national governmental regulat ons.If export shgxrlent and I am the Primary <br /> Exporter,I cartify that the contents of fhis cosiynmerit.conform to the tarts of the attached EPAAdmowledgmenl of Consent <br /> I certify that the waste mintmzation,statement identified in 46 CFR 26227(a)(If I am alarge quantity generator)or(b)(rfl am a small quantity generator)is true. <br /> Generatorslotfera's Pd ed Nam Signature <br /> Month Day Year <br /> jZ J L� G <br /> ro* jY <br /> .-J 16.International Shipmentsi <br /> _I—. 11Importto U.S. ❑Export from J S. Port of entryle <br /> 'Z transporter signature(for exports only): Date leaving <br /> W 77.Trm>spoderAdorowledgment m Receipt cf Matermis <br /> Transports dntedffyped NameSignature Month Day Year <br /> O l�lE Ci �i� L <br /> tl <br /> QTransporter 2 PnntedlTyped ams Signature Month Day Year <br /> tY <br /> 18.Discrepancy <br /> 18a.Disonapancy Indication Space Quantity ❑Type ❑Residue ElPartial Rejection ❑Fufi Rejection <br /> Manifest Reference Number. <br /> 18b.Attemate,Fatuity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Ela Faculty's Phone' <br /> W18c.Signature of ARamate Facility(or Generator) Month Day Year <br /> Q <br /> rn 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 2D.Designated Fatuity Owner or Operator.Certification of receipt of hazardous erials covered by the manifest except as noted in Item 18a i <br /> P u tedlTyped Name Signature Month Day Year <br /> Wilk Lok I PF I-f#-- <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsdlete. DESIGNATED FACILMY TO DESTINATION STATE (IF REQU! EDj. ,�II <br /> 1 <br />