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11 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPIA Form 870U-22 (Rov, 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE I (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAD 982348930 <br />2. Page I of <br />1 <br />3. Emergency Response Phone <br />(800) 4249300 <br />4. Manifest Tracking Number <br />01,4054358 JA <br />— <br />5,Gena`%1sk?68M`8qI Me, Generators Site Address (if different than mailing address) <br />123 W SONORA STREET <br />STOCKTON CA 95203 <br />Generators Phone: 209 4665-9704 <br />6, Transporter 'Co pVnName U.& EPA ID Number <br />ASBU NVIRONMENTAL SERVICES CAD 028277036 <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Design's &AVAINYEAC"490LOGIES LLC U.S. EPA 10 Number <br />5375 SOUTH BOYLE AVENUE <br />LOS ANGELES CA 90058 CAD097030993 <br />Facility's Phone: (323)277-1500 <br />go, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11. Total 12, Unit 13. Waste Codas <br />HM and Packing Group (If any)) No, Type Quantity WtNol. <br />1.NOW-RCRA HAZARDOUS WASTE, SOLID (METAL -GRIND �00" <br />181— <br />t- <br />0 <br />0i <br />D N <br />P <br />2. <br />caw <br />3. <br />C <br />14. Special Handling Instructions and Additional Information <br />EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 NAERG# 981:171 PROFILE # 9131: AP203469 METAL GRINDINGS <br />APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT-'- /)2,--1-7--ZL2 <br />64a?(311 /A - 0 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper at riong name, and are classified, packaged, <br />marked and labeled/placarded, and are In all respects In proper condition for transport according to applicable4ntemational and national governmental regulations. It export shipment and I am the Primary <br />Exporter, I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I I codify that the waste minimization statement Identified In 40 CFR 262.27(1) (111 am a large qurtntily gonarater) or (b) (61 am a small quantity gorootor) Is true. <br />PrhrileCyped Narita Signature �Yoa <br />I <br />XAI�K/COGS®I J I X(' <br />r 1 <br />- <br />16, International Shipments n Import to U.S. ❑Export from U.S. Port' entryle'xil.- --ZI-4r . . .... ms <br />3; <br />Inuisportor signature (for exports only); Date leaving U,S.: <br />L W <br />17. Transporter Acknowledgment of Receipt of Materials <br />1�24 <br />ifief I Pdinteff, yped, N Signature, Mont Day Year <br />0 0 <br />CL <br />0 <br />1, 4V 10151 <br />Z :Z <br />eficans <br />Ira Pd., 2 P, n yp.d Hams tura Month Day Year <br />18. Discrepancy <br />181. Discrepancy Indication Space F] ou,mity, []Type Ft=, Ortial Rejection El Full Rejection <br />I So. Altornwe Facility (or Gem(ator) U.S. EPA 10 Number <br />ss <br />F.6fity's Phone: EZRA AD rw <br />18c Signature of Alternate F -Tilly (1), —Ge-ator) <br />Mot181 Day sae <br />P E R M I T/ S E R V! C <br />I Hazardous Waste Report Management Method Codes (Loo codes for hazardous waste treatment disposal, and recycling systants) <br />LU <br />1 <br />3. <br />4. <br />20,M�;igniledf`a I ty Owner or Operator: Cedifficadogof receipt of hazardous materials covered by the manifest except as noted In Item 188 <br />rid y' Name Sgna onth <br />EPIA Form 870U-22 (Rov, 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE I (IF REQUIRED) <br />