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P'—%a%a % IF;— A..,;,,.,ad fnr r iso nn elite W-IrAlhhl i mau niti <br />Form ADAroved. OMH No, 2050-0039 <br />EPA'Form87DO-22(Rev,M5) PM%,Jmse%dibonsare ohlMete, DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1' Goner IA IL 0 Number <br />4 1 5 4 6 0 <br />2, Pag 1 of <br />3. EM �sga+u 3r a <br />l7 114�� OODD016766955 <br />B411afllfeSt Tracking Number <br />J J K <br />WASTE MANIFEST�y <br />S Gemernftr��s�,F1U1 g hl l r rgsg GDmra V's Site Address (If different pram mal ng address} <br />2050 E LOU ISE AVE <br />LATHROP CA 95330 <br />209 858-4110 <br />Genq�lmlR PW*:p <br />s T 6 A.SBUR 7NtI RONMENTAL SEt�VlCES U.S. �tf4i�"68 2 7 7 0 3 6 <br />7. ranrrpnrler z Cr rri Ramo U.S. rJ'A 10 bhrrnbor <br />8. Designated FacVy Name and Sile Address U, S. EPA ID Number <br />US ECOLOGY VERNON INC <br />5375 SOUTH BOYLE AVENUE <br />LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br />Faci%'a Phone:(323)277-1500 <br />9e <br />9b. U.S. DDT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />% Containers <br />11. Tolal <br />12. Unit <br />13. Vyasle Cedes <br />No. <br />Type <br />HM <br />and Packing Group (If any)} <br />Quantity <br />u'(.Nal. <br />NON-RCRA HAZARDOUS WASTE, SOLID, (OILY SOLIDS W/ PAPER <br />392 <br />w <br />FILTERS) <br />D <br />/ <br />d (� <br />P-- <br />—I <br />l <br />w <br />x <br />2. <br />w <br />0 <br />_ <br />--I <br />4. <br />w. 5podat Hamdl€ng Instracilms and AddlSlonal lnformahon <br />EMERGENCY CONTACT ; CHEMTREC 1-800-4249300 NAERG# 9131. 171 * PROFILE # 9131: P209299 OILY SOLDS W1 PAPER <br />FILTERS * P500-00025206 * APPROPRIATE PERSONAL PROTECTIVE EQUfPMEIV7��` L}/ %�3 P 23 S --o <br />15. GENERATOR'SIOFFEROR'S CERTiFICATiON: I hereby declare that the contents of this consignment are fully and accurately described above by The proper shipping name, and are engi8od, packaged, <br />mer ped and lebeledipiacarded, and am In A respects In proper condiflon for transpod according io applicable Wemationai and national governmental regulations. If export shipment and if em the Primary <br />Exporter, I certify that the conlenls of this mnslgnmant cotrfnrm to the terms of the affachad EPA Acknowledgment of Consent. <br />1 Cediry that the waste mintmizallon statement Identlfled in 40 GFR 282.27(a) (if I am a larga quantity generelor) or (b) 0fl 1 quenfiiy generator) Y yue. <br />Gcrlemtes/OBamr's Pthded !`5"d N rrnl S grraiura Monti) Logy Year <br />WernrYki(d 911 <br />❑ rnpari to U.S. ❑Export from U.S. e� <br />— <br />Trantp-vtar a+rg Wns (frit exprxte a*,): Date aavtrg U.S.: <br />= <br />17. Transporter Acknowledgment of Receipt of Materials <br />Fr i Prtntadriyf➢ad Manch Day Year <br />NWM <br />A0,. <br />/ <br />Tmn*mmWr WrtkWdfryprad kar4 ura Month Day yew <br />18- Discreaancy <br />189. Discrepancy indication Spec quantity ❑ Type ❑ Residua ❑ Partial Rejectlon ❑ Full Rejection <br />ltrAlfeas ReWsnce Number. <br />18b, Allernote FACRY jor Ger*nralix) u.S, EPA ID Number <br />u <br />Faciliys Plrana: <br />18c. C gn9turo of AtTerraie Fa#Gty far Gerrarafor) <br />menbri Day Year <br />a <br />a <br />y19. <br />Hazardous Waste Report Managomenl Method Codes 0a., Ludes for hazardcus waste tlealmani, &posal, and recycling systems) <br />wo <br />i <br />4(41 <br />2. <br />1 <br />3. <br />d. <br />20 Deaignetad FRdRy Owner or tat Cartifimflon ofmcefpt of hazardous materials revered by the manifest except as aded In Item 18a <br />P tine tiro WrAtin Clay Year <br />,, CJ c-2— <br />yis <br />EPA'Form87DO-22(Rev,M5) PM%,Jmse%dibonsare ohlMete, DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />