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017696912JJK <br /> Please print nr type.(Form designed for use on elite(12-pitch)typewdten) Foml A ved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page 1 of 3.Emergency Response Phone 4.M nNst7racWingNumbor <br /> WASTE MANIFEST I CAE 0 0 0 2 6 413 2 1 (800)424-9300 01769691 2 J J K <br /> 5.Generators Name and Mailing Address Generators Site Address(If different than mating address) <br /> 711 MATERIALS INC-711002 <br /> PO BOX 3191 <br /> MODMO CA 95354 2714 STAGECOACH <br /> Generators Phone: 209 943-4730 STOCKTON CA 95215 <br /> 6.Transporinr 1 Company Name U.S.EPAID-F&M Ker <br /> WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Traimporfar 2 Company Namrr U.S.EPA lU Number <br /> 8.Designated Facility Name and She 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 /> FaciliVaPhone: (3231277-1500 <br /> 9a• 9b.U.S.OOT Description(Including Proper Shipptng Name,Hazard Class,ID Number, 10.Containers <br /> HM aW Per*Ing No. Type Quantity WINoI. <br /> Group(it any)) Tata) 12.Unit 13.Wasts Codes <br /> Qu <br /> '-NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) 352 <br /> 0 <br /> �}� <br /> W , DM P <br /> a 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Insbuctions andAdditional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-600-424.9300 WOES TERMINAL CERES CS NAERG#981:171*PROFILE#9131: <br /> AP201815 OILY SOLIDS*P500-00060090*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT _217- 3[a <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:1herebydedarethatthemrdenUofihlsxxnslgnmentareUyanda=rmietydesetibedaboveby8npropershippingname,andamclassified,packager(, <br /> marked and tabeledfplacarded,and are in all respects in proper condition forlrawportaox orrRnp to applicable intemationaland ndonal governmental regulations.11 export shipment and I am the Primary <br /> Exporter,I certify Thal the contents of His consignment confacm to the terms of the attached EPA AGawwil dgmenl of Consard. <br /> certify that the waste mtnimtradea statement identMed In 40 CFR 26227(a)(If I am a lenge quantity generator)or(b)(KI am a small quantity generator)Is We. <br /> Genefator;aY7.emrs Pdnledlfypad Name Signat m Month Day Year <br /> [ ` Q d <br /> --r 15.International Shipments <br /> r__ ❑lmponttoU.S. ❑ExpommmuS. Portotenvylefdt <br /> 9 Transporter signature(for exports only): Date leaving U.S.: <br /> a 17.TranspoderAdogwt*merdofReceipt ofMaterials <br /> aTfansportor 1 PdntcWyped Name Signa ba>3 Morrill Day Year <br /> r Sao,& 109101 its <br /> 20 20 Transporter2 Printed Typed ame v Signabrre Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑quantity U Type ❑Residue ❑Partial Re)ection ❑Full Rejection <br /> MRnirest Reference Number. <br /> 18b,Alternate Facility(or Generabr) US,EPA 10 Number <br /> J <br /> V <br /> 14 FacilltYs Phone: <br /> w 180.Signature elAltemete Facility or Generator) Mont Day Year <br /> Q <br /> 2 <br /> 19.Harardous Waste Report Management Method Codes(.s.,codes forhazardous waste treatment,disposal,and recycling systems) <br /> c 1. 2. 3, 4. <br /> 20.DestgnotA Feedity 0uaarr or 0perotor Cer1JflmWn of receipt of hazardous mateflals wvered by the manifest except os noted In Item 16a <br /> Prinb4lyped arna r Signature Month Day Year <br /> aV1 <br /> 9.0 <br /> OKI <br /> EPA Form 8700-22(Rev. -05) reviuuseffonsore obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />