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Please print or type.(Form deslgndrl for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.ManitestTracking Number <br /> WASTE MANIFEST CAL000301999 1 (800)424-9300 016369623 J&- <br /> 5.Ganaraloes.Name and MallinAddress Generator's S1taAddress cif different than malting address) <br /> CEMEX ;Dtiii, -4461 <br /> 3990 CONCOURS STE 200 <br /> ONTARIO CA 91764 30350 S.TRACY BL <br /> Generator'sPhonw 209 993-7454 TRACY CA 95377 <br /> 6 Tr-,.n s porter 1 CompanyName U.S.EPA ID Number <br /> ASBURY NVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> T.Transporter 2 Company Name U.S.EPA 1.0 Number <br /> 8.Daslgnated Facility Name and Site Address U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD097030993 <br /> Facility's Phone: (M)277-1500 <br /> ga, 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 Packing Group(if any)) No. Type Quantity wt./Vol. <br /> 1• NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID,PAPER FILTERS 352 <br /> 0 <br /> DIS 11,0 P <br /> Z 2. <br /> W <br /> JUL 11 2017 <br /> 3. <br /> B� <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 *PROFILE#9B1 :030817-01 OILY SOLID, PAPER FILTERS <br /> P500-00027064 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 4L <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuraleiy 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 regulktions.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 EPA Acknowledgment of Consent- <br />' I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gan�rator)or(b)(if 14 m p small quanfily generator)is true. <br /> Ge lor' fferces PrintedfT ed Name 191 t4or Month Day Year <br /> 1 ,1 Ati[�� . � 5 is ii <br /> –J 16.International Shipments ! <br /> F– <br /> El import <br /> Import to U.S. ❑Export from U.S. U Port of enlrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> TragsRarter 1 Prfnt9Fypevame i Signature Month Day Year <br /> CL <br /> ) l � <br /> zQ <br /> Transporter 2 Printed yp d Name Signature Month Day Year <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity L1 Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U-S-EPA ID Number <br /> J <br /> c� <br /> LL Fadilty's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1 J 2 3. 4. <br /> I , � 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prm1edffyped Name [ Signalure _f Month Day Year <br /> )J <br /> EPA Form 8700-22(Rev.3.05) 'Previous editions are obsolete. II±SIGNATED FACILITY TO GENERATOR ' <br /> v <br />