Laserfiche WebLink
D-3c-03-08 13:37 From-DK Dixc 17076782339 T-445 P.005/009 F-886 <br /> Fxm Approved.OMB No.2050-0039 <br /> Please print or type.(Porn deal, nod for use on elite(12 Itch) ewrlter, <br /> 1,Generator IDN mbar 2.Page 1 or J.Emerpancy Response Phone 4.Manifest am ' JJ K <br /> UNIFORM HAZARpoUS 0, A 1) 2 8 '2 1 7 0 l, 5 t (OOo) 424-9 005102904 <br /> WASTE MANIFEST <br /> Atii3U1'tY ttVYI�N Generators Site Address(If different than mailing addrasa) <br /> 5.Genera a T SERMCES- <br /> 1 jaa s.SANTA FE AVE C� 90 21 <br /> r,0%fT0N AOa 974- 4 <br /> Generators Phone; U.S.EPAIA Number <br /> 6,Transporter 1 Company Name C A D 0 2 B 2 7 7 0 3 6 <br /> ASBURYE-WRONKNTA SEROCES US,£PA IO Number <br /> 7.Transporter 2 Company Name <br /> U.S,EFA 10 Number <br /> 8,Oeslgnata0 Faclll Name end Sao Address <br /> nRAAN p,E A'F ' 1l,+ NTAf. <br /> 1616 S. THRIVE RO CA <br /> WEST SACRANEN 0 1 C A p 0 4 4 0 o 5 5 6 <br /> p1613T1-5747 <br /> Fae li a Phone; <br /> In Name,Hazard Claes,IA Number, 10,Canrainera 11,Tottl 12.Unit 13.Waste Codas <br /> 9e. 9b.U.S.DOT Aescrptton(including Pro SMpp g No Type Quanby W6/Vol, <br /> HM and Packing Group(if any)) <br /> NON-RCRA HAZAADUUS ASTM, Uc�l�lp ( 1HYl EN6 GI. cx p a i T T <br /> SOLUTIONS) ` <br /> 3. <br /> 4. <br /> 14,Special Handling Inatrudlons and Additional Infannet on <br /> %AEf�l3* 991 T r1 'PROFILE 1081 )-THYLENE nLYCOl.29-40%. OIL 1 5%, WA'(ER 56 TIi96"11PpROPI4IATE PERSONAL <br /> PROTECTIVE EQUIPIVENT <br /> 15. GENERATDR'SIOFFEROWS RRT1FICATION: I hereby dedera that the conlante of this consignment aro fully and accuratay described above by the proper shippinlj name,and are classified,packaged, <br /> merkotl and lebeledlplararded,and are In ell respects in proper condition for tninspon according to applicable intemadanel and national govemmontal rag,latlons.if export shipment and I am the Primary <br /> Exporter.I csriN that the c❑,ents of this consignment conform to line tarma of Ire attached EPA Acknowledgment of Consent. enaral❑r i True. <br /> I canify that the waste minimization statement idenitfied in 40 CFR 282,27(a)(A 1 am a large quantity generator)or(b)(If I am s smell quanu y g ) <br /> Signature ( Month Pay Year <br /> Genarat❑e& es Pn tadrryped me <br /> J �� I <br /> le.Intemabona Shipments Import U.S. ❑Export from U.S. Port of entry/0 <br /> Qale leaving U.S.: <br /> Transporter sipnalure(for exports only): <br /> i',,Tranxp eler Acknowledgment of I4eceipi of M (� Month Day/ "ear <br /> Troreponer 1 p�rR►Vy Name Signature I ( (} HO I 2'"l 'J <br /> t I(} c. 1� C tl J <br /> r Month Day Year <br /> Transporter 2 ,nledlTyp Name <br /> Signature <br /> 18.Discrepancy <br /> tae,Discrepancy Indication Space E ❑Type <br /> ❑Residua ❑Panlel Re)acllc�n Full Re�ectl❑n <br /> Mandaet Reference Number, <br /> U.S.EPA 10 Numier <br /> 18h,Alternate Facility(or Generator) <br /> Facititys Phone; Month Day Year <br /> 18c.Signalurs of Alternate Faulity or Genarato <br /> 19.Hazardous Waste Report Management Melhod Codes(i.a.,codes for hazardous waste treatment,disposal,and raoycang 8y51ems) <br /> a. <br /> 20.Designated Facillly Owner or Operator.Certlicii1ion of receipt of hazardous matehsis covered by the manifest except as noted in Itam 1 Ba Month Day Year <br /> Signature t' <br /> ritwy me <br /> WAF H700 22 IRev,J-0) Previous edilidli obsolete. DE b3NATED FACILITY TO GENERATOF <br />