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UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 01 9 9 —. (8W)424-Ml J J K, <br /> 5 Generator's Name and Mailing Address 21 Generatoes Site Address(if different than mailing address) <br /> CEMEX READYMIX-4461 <br /> 3990 CONCOURS STE 200 <br /> ONTARIO CA 91764 30350 S TRACY BL <br /> Generatces Phone: 209 993 CA <br /> TRACY" CA 953•'x' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 E <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Desigrated Facility Name and Sh Address U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 900.58 C A p 0 9 7 0 3 0 9 9 3 <br /> Facillil Ps Plaine ^7 <br /> ga Qb U,S,DOT D-90tiOn Cmduigq Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM arndPaekg9Ga4(Iei No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. NON-RCRA HAZARD0118 WASTE,SOLID(OILY SOLIL))PAPER+41' <br /> 0 <br /> a <br /> w <br /> z <br /> w <br /> C9 <br /> i <br /> S <br /> 14.Spada)Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 14004,24-9300 PROFILE#9BI 030817.01 OILY SOLID,PAPER FILTERS s <br /> P1500.00027064 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATORMIOFFEROR'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 tabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Expnrier,I certdy that the contents of this consignment oepform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste rrfff tion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quandty generator)is true. <br /> G=_neraWs/lOfferoesPnnUx TypdMarne Si nature Month Day Year <br /> J i6.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Trans ar signature fore its <br /> Port nature 9 ( exports only): Date leaving U.S.: <br /> w 17.TransporterAdmowledgment of Receipt of Materials <br /> Transporter 1 PnntedNTyped Name Signature <br /> 0 } Month Day Year <br /> N "Ay Ccw—!_ ! <br /> Z Transporter 2 Printeryped Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity (jn Residue <br /> D v ❑Partial Rejection ❑Full Rejection <br /> flanifest Reference Number <br /> 18b.Alternate Facility(or Generator) I SL11 U.S.EPA ID Number <br /> J <br /> LL Facility's Phone: IMV• Iv1Yr`^f�� <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> a Month Day Year <br /> z <br /> 0FHaz-ardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w <br /> O 2. 3. 4. <br /> r <br /> 20.Designated Facility Owner or Operator:Certlfleatlon of receipt of hazardous materials covered by the manifest except as noted in Item I&a <br /> Pnnted,yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous edltlons are obsolete. <br /> DESIGNATED FACILITY TO GCiVEt1AT ;;, <br />