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018233579JJK <br /> Please print or Form designed for use on 01 10(12-pitch)typewriter.) Form A <br /> 1.Generator ID Number Ppmved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS 2 Pags 1 of 3.Emergency Response Phona 4. anllost Tn ng Number <br /> WASTE lNANIFEST CAL 0 0 0 2 2 2 2 7 9 1 (800)424-9300 <br /> 5.Goneralor'sNamcandMaJil% dress 0 g <br /> 2 3 3 5 7 9 J J K <br /> NIXON-EGLI EQIPMENT Genorarors 5aAddras3(dilfarom than mailvyacdr ss) <br /> 2044 S.VINEYARD AVE <br /> ONTARIO CA 91761 800 GRANTLINE RD <br /> Generalar's Phona: 209 830-8600 TRACY <br /> S.TransporterICompany Name <br /> CA 95304 <br /> ASBURY ENVIRONMENTAL SERVICES U.S.EPA ID Number <br /> CAD028277036 <br /> 7.Transporter 2 Company Namo <br /> U.S.EPA ID Numbor <br /> 8.Des*nal edFaalrtyNam and SieNddrass EPA ID Number <br /> US ECOLOGY VERNON INC U.S. <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 <br /> Facrdy's Moe 323 277-1500 CAD 0 9 7 0 3 0 9 9 3 <br /> ga. 9b.U.S.DOT Desaip"an pnalydirg Proper Shlpptng Nama,HoardClass•ID Number, 10Contalne s <br /> HM and Padmg Group(U any)) . 11.Total 12.Unit 13.1Mas(a Coees <br /> � 1•NON RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) No. Typo r;uanuty WLNd <br /> ' QQ 352 <br /> 2. <br /> tu <br /> 3. I <br /> 4. <br /> i <br /> 14.Spedal Hr�dlig lnsbuiom and Admtional Information <br /> EMERGENCY CONTACT;CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS NAERG#981:171*PROFILE#981 <br /> AP172510 01LY SOLIDS x P500-0=50602 'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT '171 <br /> 15. GENERATDR'SIOFFEROR'SCERTIFICATION:I horeby declare thaltho contours 01(1115 mnsigrunont are fully and accuraiely descnbod abave by" <br /> m Jkad and lexlaNplacardcd,encl aro to a0 reser ctr In Y Proper shJpping name.and era dassined, • <br /> Proper mnd&m for tmnspart otxorrfng b applcable Inlemational and national gnerrtmonlal regulabcm.If a5Tw1 shpmmt and I am the Primary <br /> Evcdef,I oaUfy that fife cordents of this consigrrnent curdann to the terms of the attached EPAAdmowledgmenl of Consent. <br /> I carff y t%st tho wasL-mhdmzatbn sL&manl Idmtf6ad in 40 CFR 262.27(e)(f I am o large qumik generator)ar(b)(f i am a <br /> bfalOtfa <br /> SP, Name 4enaa <br /> C r sti4>.� Day ear <br /> 16_Intern anal Sb'pments <br /> ? T ❑Import to U.S. ❑Er.,A S. Port of ontrylezU: <br /> rartsporersgnahrm(forc�ortsar�y): DatelaaNn U.S.: <br /> w 17.TantporlerAdutaeladgmenlorRoealpte(Mattie 0 <br /> Transpo ler i PdnlodlTy)od Signature March Yea <br /> o jj <br /> a <br /> Tansparter2PrnledlTypadNama SfpnaNm <br /> �t Month Day Year <br /> 18.DLsacpanry <br /> 18a-Discrepancy Indication Space <br /> ❑OWinitty ❑Type ❑Res clue ❑Part alRaadfon ❑Full Ro)oc6on <br /> 18b.Aftemate Fadi ty(or Generator) Ma rites!Retemna Number. <br /> —r U.S.EPA 10 Number <br /> U <br /> uQ.. Fadliyrsftne <br /> 18c.Signature MAkamaA Fack7fy(a Generator) <br /> iMardi Day Year <br /> y19.Hazordous Waste Report Management Method Codes(Le.,codas for hazardous wasto troabnent,d sal,and r <br /> 110 1. 2. I'P0 ��9 syslmn) <br /> 3. 4. <br /> 20.Desk trod Fad4ly DNrreror Operator CartF,calbn cf recotp!of hazardous matedals eovarcd by Uro man*sl except as rndad In Ilom 18a <br /> Printed/Typad Name r— g ao a' <br /> ro Mot Day der <br /> .PA Form 8706722(Rev 3 a5) Prev ous editions are o ele. DESIGNATED FACIL.IT`(T STINATION STATE(II`AEQIf1RIED) <br />