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f»a•T504545; • <br /> Please print or type.(Form designed for use on elite(12-pitch)k pewriter-) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Num4.ber 2.Page 1 of 3.Emergency Response Phone manifest Tracking Number <br /> WASTE MANIFEST I CAC 0 2 8 2 7 7 0 3 6 i 1(800)4249300 Q 18 2 3 3 8 4 4 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 S.SANTA FE AVE <br /> COMPTON CA 90221 <br /> Generator's Phone: 310 886.3400 <br /> fi.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company dame U.S.EPA Q Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICE-CERES <br /> 1920 MORGAN RD. <br /> CERES CA 95358 CALO00393680 <br /> Faeifdys Phone: 09 5 1-1825 <br /> ga 91b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Conto!Hers 11.Total 12,Unit <br /> HM and Packing Group(if any)) Na. Type Quantity 44tIVol. 13.Waste Codes <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL 133 <br /> SOLUTIONS) <br /> 001 TT G <br /> y12 <br /> U- <br /> w <br /> C9 <br /> 3. <br /> 4, <br /> 14,Special Handling IrulructcnsandAdditional Information <br /> EMERGENCY CONTACT:CHEMTAEC 1-800`4249300 WOES TER N : *APPRORIATE PERSONAL PROTECTIVE EQUIPMENT* <br /> EMERGENCY CONTACT CHEMTREC 800 424 9300 *TRUCK# V <br /> 15. GEN ERATOR'SfOFFEROR'S CERTIFICATION. I hereby declare that the oenlents of this consignment are fulry and accuralely described above by the proper shipping name,and are dassi fkd,packaged, <br /> marked and Iabeledlplacarded,and are in 21 respect in proper condition for transport according to applicable intemati anal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I oertify that the contents of this consignment eonfonn to the terms of the attached EPAAcknowtedgment of Consent. <br /> I certify that the waste minimization statement ide ntified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quay tor]is true. <br /> Generators1CfferorsPrintedlTyped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑I mpod to U.S. ❑Enodfra Port of entrylex+t <br /> Transporter signature(for exports only): Date leaving U.S.: Y <br /> ce 17.TransporterAcknavAedgmerit ofReceipt ofMate rials ; 4+•e?��; w;s' <br /> Transporter PdriledfTyped Name C Signature r .�Nbnth .EDway_ Ym <br /> d Transporter 2 PilntedfTyped Name We r'•Momh pay Ym <br /> 18,D:s-repanoyter- <br /> 1 Sam Discrepancy Indication Space ElOuantty ElType ❑Residue ElPartial Rejeclien ❑Foil Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U-S_EPA I D Number <br /> J <br /> r:] <br /> rdi Facility's Phone: <br /> 18c.Sig nature of A11errrate Factifty(or Generator) Month Day Year <br /> d <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1, � 2. 3. 4- <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered try Die manifest except as nded in Item 18a <br /> PdnledlTyped Name d Month Day Year <br /> Lim <br /> EPA Form 870x22(Rev-3.05) Previous editions are obsolete- DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> _� 12828.1136 <br />