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Please print or type,(F'om1 designed for use on elite.(i2-pitch)typmIlef.) FormApprvved,OMB No.2050-0039 <br /> 1.Geneel r 1pr14 er 2.Pag 1 n1 ?.Fme �f l*;i 1" 01..6772925 <br /> Manifest Tracking Numbef <br /> UNIFORM MANIFESTS D J 19 6 7 6'8 0 ( ! JJ K <br /> WASTE MANIFEST <br /> g, Generatoes,Slle Address(f different Nan malling address) <br /> 3333 AUTO CENTER CIRCLE <br /> siuCniuiV CA 95212 <br /> 209 477-3668 <br /> Ceneralor's Phone: <br /> 6.Trans prla 1 Cemvar�Nama U.S.EP6 IA tb'q'�8 2 7 7 0 3 6 <br /> F.513URY FAIRONMENTAL SERVICES <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facillly Name and Ste Address U.S.ER41D Number <br /> US ECOLOGY VERNON INC <br /> 5973 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 C A D:0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: (323)277-1500 <br /> ga, 9b..U,S.DOT Description Qncluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 41.Total 12.Unit <br /> and Packin Group d an Quant Wtivol. 13.Waste Codes <br /> HM 8 p( y)) No. Type Quantity <br /> 1 NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID, PAPER FILTERS) 352 <br /> 0 D N / A� P _— — - - - <br /> L <br /> 3. J <br /> i <br /> 4 ) <br /> 14.Special Handling Instructions andAdditional Information W� <br /> EMERGENCY CONTACT: CHEMTP,EC 1-800-424-9300 *PROFILE#9131:02/22/2017-03 OILY SOLID, PAPE�TERS <br /> P500-00025818 "APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT - <O / IAS 3 <br /> 15. GENERATOR'51OFFERDR'S CERTIFICATION:1 hemby ds!clare IWI.the content.of Ihis consignment are(oily and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked end labsledlp!uardod,W ere In a[fespact3lm proper candion for bampo:t according Ir'applicable international and nagomal governmental regulations.If export chipmant and I am lh'o Primary <br /> Exporter,I cerlily 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(a)(•d I am a large quantity generator)or(b)(if I am.a small quantity generator)Is true. <br /> Gerlefo r}Italtcoes PrintadfTypad NPV Slgnelu Month Day YON <br /> 16.InLemalroral Shiprmenis <br /> ❑Importt4s. ❑Export from U.5. <br /> Transporter agraldto(for eapor's onlyr Date komrfr p U,S <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Assns 1 PrintedTyped(Jame Slgnatura Menlh Day Year <br /> � F k•- .,� ter-- `^ d-3 i� � <br /> Z Transporter 2 Prinled)Typed ame ore Month Day Year <br /> d <br /> cc <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity F-1 Type Residue Partial Rejection ❑Full ReJeclion <br /> Manifesl Referenca Number. <br /> F 18b.Altomata Faality(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facilitys Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> co19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1, 2. a 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 /> PrinledfTyped Name Sgnalure Month Day Year <br /> EPA Form 87`70-22(Rev.3-0�) Previous ediliorrsare obsolete. DESIGNATED FACILITYTO DESTINATION STATE (IF REOUInED) <br />