Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form:Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.Manifest TrackIng Number <br /> WASTE MANIFEST C A;(J 3 z3" 2 E3 'S (3t�Ot 9 �5U0 a._ '�� <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> PHILL,IP$At1 I'ta BARE <br /> 100S MOFPAt BOULEVARD <br /> IV ANI EfCA CA 9-5-336LVA ivt r ! Ca!i�L% <br /> Generators Phone: 1 ]71 ` N"iAiy s b;A CA G5ZI-54 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> WORLD SOIL.ENARONIV ENTAL.SF.f?llft:,ES 0 A 0 x 8 2 i' 10 3 s <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 53:5 SOUTH BOYLE AVENUE <br /> LOSANGELES CA 90058 <br /> CA£32:79'70 3ti�99W <br /> Facility's Phone: (32,1)277-1500 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit <br /> 13,Waste Codes <br /> HM and Packing Group(if any)} No. Type Quantity Wt.Nol, <br /> 1-I`.Irj'N-RCRA I f ?ARtO.G;US WASTE,-SOLIG(BRAKE WHE SryAANr,Sj �}�: <br /> r <br /> w <br /> M 2 <br /> LU <br /> c7 f <br /> 3. <br /> 1 <br /> 4. # <br /> f I <br /> 14.Special Handling Instructions and Additional Information <br /> t EtlEFit t {; NTACs :G'I"}EN4TFEC J ,Q,00-424-9300'OE's° ERLvrs14P,[..cERFS C I�P011—il Y= 2, ,:G=,2020—:l.-`.�-01 <br /> -:� E'`'LF` 'r � <br /> LAI HE SHAY IW-jS 'e P500-00058543 *APPROPRIAT€:.PERSONAL.FRO+ E0J]VE EQUIPI',rt 14 f <br /> 74 <br /> 15. GENERATOR'SfOFFEROWS 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 labeledtplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulatfons.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity gene€ator)is true. <br /> Gene r icrslOfferor's Printedrryped Name Si nature Month Day Year <br /> 16.international Shipments; 1 <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> a Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials a <br /> Transpvrte 1lPrurtedffyped NameSignature r Month Day Year <br /> ` i�i�'d..�fl�i �,_k'" j �...a•�' �-1,.6'����-�t!�F. r J t<' r •d ��. <br /> Q Transporter 2 P edlTyped Mme Signature ° Month Day Year <br /> � If <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ j ❑Full Rejection <br /> ❑Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> J <br /> rat Facility's Phone: <br /> W 18c.Signature ofAltsrnate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> rn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01. � f �� 4 2. 3. 4. <br /> , 3 f3 <br /> 20.Designated f=acility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 <br /> PrintedlTyped Name Signature fy Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />