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Form ADDroved. OMB No. 2050-0039 <br />EPAforrn 8700-22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE: UP RhUUlhitu) <br />UNIFORM HAZARDOUS <br />1• Generator ID Number <br />CAL 0 0 0 3 9 6 5 01 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />(800) 42¢9300 <br />4. Manifest Tracking Number <br />017468456 JJ K <br />WASTE MANIFEST <br />5. GeneralWa¢+a agd.btailippfth .ICE CENTER Generators Site Address (if different than mailing address), <br />1131 HOLLY DR <br />TRACY CA 95376 <br />209 835-6900 <br />Generator's Phone: <br />Q� C Na U.S. EPA ID Number <br />6. Transp/%S�tlJfo'���IMONMENTAL SERVICES CAD -028277036 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facili Name and Site Address U.S. EPA ID Number <br />US ECROGY VERNON INC <br />5375 SOUTH BOYLE.AVENUE. <br />LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br />Facility's Phone: (323)277-1500 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNol. <br />1• NON-RCRA HAZARDOUS WASTE, SOLID (OILY SOLID, PAPER FILTERS) <br />. <br />75` <br />352 <br />DM <br />P <br />z <br />' <br />2. <br />w <br />U <br />3, <br />4. <br />14. Special Handling Instructions and Additional Information <br />EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 *PROFILE # 9B1 : 072517-02 OILY D APER FILTERS <br />\/ <br />P500-00038445 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT '- 3c> <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 classified, packaged, <br />marked and labeledfplaearled, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />CW' <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (If I am a smal uantity generator) <br />General s rot'sAftLeed NaV Sign lu n Month Day Year <br />VL I <br />--r <br />i— <br />16. Inter ' Shipments ❑Ex from U.S. nd of a exit: <br />Import to U.S. pat <br />Transporter signature (for exports only): Dale leavingU•S.: <br />w <br />17. TransporterAcknovdedgment of Receipt of Materials <br />O1/7 <br />Transporter 1 PdntedrTyped Na Signature Mon Day Year <br />/' JT <br />IL <br />QTransporter <br />2Printedrtyped'Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number:' <br />.18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />Oa <br />Facilitys Phone: <br />C3 <br />18c. Signature of Allemale Facility (or Generator) <br />Month Day Year <br />Z <br />y19. <br />Hazardous Waste Repotl Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />20. Designated Facility Ovmer or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />rtedrryped Name Signature Mohth Day Year <br />EPAforrn 8700-22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE: UP RhUUlhitu) <br />