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i <br /> Please print or for use on elite12 Form. 4 DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator D Number 2 Page 1 o' 3.Emergency Response Phone- 4.Man e4t ng Number <br /> WASTE MANIFEST CAL 0 0 0 3 6 6 21 1 1 I800)424-9300 018233928 JJ K <br /> r£ Generators Slte dress(ddiferent than mailing address) <br /> FIRESTONE#028746 <br /> 726 E.HAMMER LANE E <br /> STOCKTON CA 95210 <br /> Generatees Phone: 209 953.-2403 <br /> 6,Transporter1Corn nyName U.S.EPA ID Number <br /> A$SURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Compliny Name U.S.EPA IDNUmbatI <br /> ' I <br /> &. U,S.EPA ID Number p <br /> DEMENNO/KERDOON <br /> 2000 N.ALArMEDA STREET <br /> •-tOMPTON CA 90222 CAT080015352 <br /> 8 <br /> Ia. 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 Paeldng Group(f arty)) r No. Type Quantity WtN01; <br /> 0 1'NON-RCRA HAZARDOUS WASTE,LIQUID(BRAISE FLUID) 343 <br /> s DM G - <br /> z z <br /> 3. <br /> 4. <br /> 14.Sp al andling ns ructions an ona I rmabon <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL-CERES CS NAERG#9131:173.•x'PROFILE#9131: <br /> 375894 BRAISE FLUID'X *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 2—o <br /> 15. GENERATOR'SIOFFEROR 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 labeledfplacarded,and are in all respects in proper condition for transport according to applicable Intemationalamf national governmental regulations.If export shipment and I am the Primary <br /> Exporter,t cerllly that the contents of this consignment conform to the terms of the attached EPAAclmowledgment ofCoif <br /> I certify that the waste minimization s tement identified in 40 CFR 28227(a)(K I am a large quantity gene or)or(b)(11'I all Is true. <br /> rg <br /> WX <br /> _ZY ia,Inwhiallonal ShIfirmpa <br /> j— ❑impoft to U.S. El ExpGrt from U.S, Port of enbyfexiC <br /> Transporter signature{forexports only): Date leaving U.S.: <br /> IM 17.TransporterAcknowledgmerd of Receipt of Materials <br /> b Ylear <br /> Signature Month Day Y r <br /> a I <br /> t— <br /> Ill.Discrepancy r I <br /> 18a.Discrepancy indication SpaceQuantity �7ype QResidue ❑Partial Refection EJFull Reiecdon <br /> lab,Altemate Facility(or Generator) U.S.EPA ID Number <br /> � S rIi <br /> WE FaciillysPhone: i <br /> W 18c. gnaturs of terra a ora or emerald Month Year i <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 2 3 4. <br /> 20,Designated Facility Owner or Operator Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name Manth Day Yea <br /> i <br /> EPA, 22'(Rev.3-04 are obsolete. DESIGNATED•i TO'L D STi TION STATE(IF REQUIRED) I <br />