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018233646JJK <br /> Please print or type.(Form designed for use on elit2'l2-pitch)typewnter.) <br /> Form Approved,OMB No.2050 0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Numbr 2.Page 1 of 3.Emergency Response Phone 4.ManNest Tracking Number <br /> WASTE s Na MANIFEST CAL 0 0 0 2 2 2 2 7 9 1 (800)424-9300 018 2 3 3 6 4 6 JJ K <br /> 5.Generator's Name and Mailing Address <br /> NIXON-£GLI EQUIPMENT ent Generators Site Address(if ddferthan mailing address) <br /> 2044 S.VINEYARD AVE <br /> ONTARIO CA 91761 800 GRANTLINE RD <br /> GpDngmaled <br /> hone: 209 830-8600 TRACY <br /> r I Company Name CA 95304 <br /> URY ENVIRONMENTAL SERVICES U.S.EPAIDNumber <br /> CADmber 036 <br /> 2 Company Name <br /> U.S.EPA ID Number- <br /> 7 <br /> umber <br /> Fadaty Name and Site Address <br /> COLOGY VERNON INC U.S.EPA ID Number <br /> SOUTH BOYLE AVENUE <br /> ANGELES CA 90058 <br /> Fad'Bys plane: (3231277-1500 C A D 0970,30993 <br /> ga. 9b.U.S.DOTDescripfion(Including Proper Shipp ng Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(d any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity mivol. <br /> ix 1' NON RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) <br /> 0 <br /> 2. <br /> D M �L. 0 P <br /> I I <br /> UJI <br /> ! <br /> 4. <br /> 14.Spatial HandFng Instrvctcre and Additionzi Intomtaton <br /> EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 WOES TERMINAL:CERES CS NAERG#9B1:171 PROFILE#951: ��e <br /> AP172510 OILY SOLIDS*P500-00050799 -APPROPRIATE PERSONAL PROTECTIVE VQUIPMENT _ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contends of this consignment are tulty and accurately described above proper shipping name,and are classified,packaged, <br /> d,and labded1placarded,and are in all respects in proper condition for transport according to appfaable international and natonal govemrnental regulations.If <br /> Fgo:ter,I certify that the contents of this ocnslgnmerd conform to the terms of the atached EPA Adkraw edgment of Consent. export shipmer t and I am to P ma y <br /> I certify that the waste minim®ton statement identified in 40 CFR 26227(a)(d I am a large quart', <br /> 6Y generator)or(b)(41 am a small quantity enerator)is <br /> Generalo sl sPrintedrypedNana rn y Signature Month Day Year <br /> en YL C�i <br /> 16.1mematonal Shiprneras ( d1 <br /> ❑Impart to U.S. ❑Export 4m U.S. Po of entrylexit: <br /> Transporter signature(for exports only):Of Date leaving U.S.: <br /> LLI <br /> 17.Transporkrg0vrow4edgmenl 01 Receipt of Materials <br /> O Transporter 1 Pent-rryped Name <br /> Signa Month Day Year <br /> CTransporter 2 Plirrted/fyped Name 10(rgnaturo Month Day Year <br /> F– <br /> r <br /> 18.Discrepancy <br /> I8a.Disaoparay Indication Space <br /> ❑ Quanldy ❑Type ❑Residue ❑Partal Rejection ❑Full Rejection <br /> JZ 18b.Ademate Fadlrly(w Generator) IAanifest Reference Number, <br /> � U.S EPA ID Number <br /> U <br /> W FaaTdys Plane: <br /> w 18r-Signature olAttenhate Facd ty(or Generator) <br /> Q Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Managemertl Watad Codes(;.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> 1 141 ,11 2. <br /> Prinled?yped Name 3. 4, <br /> 20.Designated FaciNa me <br /> owner w Operator.Certification of rmipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 Signature Month Day Yoar <br /> +V(r L' v` ��] <br /> EPA form 871)0 22(Rev.3-05) Prevats edd'arls are obsolete. DESIGNATED FACILITY TO DE ATION STATE(IF REQUIRED) <br />