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4- ease rint or e. Form designed for use elite,12- it ewriter. <br /> p type.( g Qn. ( p ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number ag f 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST i7 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> A. T&SON INC.-FRESNO <br /> PO Box 150W 4533 CffROM AVE <br /> SACRAMENTO <br /> Generator's Phone: <br /> • 95951 FRESNO <br /> 372 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVRONMENTAL SERVICES ICA0028277036 <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 /> Ott NORTH ALAMEDA STREP <br /> COMKON (A 90222 <br /> Facility's Phone: ( -71{0 CATOSOOi3352 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NOL 13.Waste Codes <br /> ® 1. O HAZARDOUS WASTE•LIQUID(MI E MLS) 0 0 1 � � 223 <br /> BEEN QUALIFIED2. <br /> - <br /> FOR REOYCEI�s 'REAPNI g 4 s i. <br /> DeMEAJ�I' r� )d ' t t s s` R E <br /> _._. <br /> 3. CTS "" <br /> C iR9 i�1f . t{ sl s; atd" �f tyy ; <br /> �'�.n"�;IT�TO�'� � r OCT : 0.-2014 <br /> Ll 335? <br /> 4. AMENTAL <br /> HE 1- 1 r*6iDT4 <br /> t <br /> 14.Special Handling Instructions and Additional Information <br /> NAERG# 981-171 PRORLE#901.18bft4*EMERGENCY comu: NE E :I €? <br /> ADDMNAL :a E E IVE EQUIPMENT <br /> 15. GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects 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 terms of the attached EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printedrryped Name Signature Month Day Year <br /> ri 16.Intgmational Shipments <br /> Export from U.S. Port of <br /> El Import to U.S. ❑ <br /> z Transporter signature(for exports only):a Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials ? <br /> Transporter 1 Printed/Typed Name f . Signature Month Day Year <br /> O <br /> EL <br /> Z Transporter 2 Printed/Typed Name SignaNw,,- Mon h Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type 1:1 Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1.t 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed. ped Name SigqaturE -a Month Day Year <br /> ,P rte`rte"® <br /> E Form 00-22(Rev.3-05) Previous editions'ar obso ete. fi DESI f`lATED FACILITY TO GENERATOR <br />