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Please pfini of lype�w, (Form designed for use on elite (12-pitch) typek'riter..) Form /\pprcvad_. Oh4B No . 2060-0039 <br /> ti UNIFORM HAZARDOUS 1 , Generator MNumber 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracf;(ng Number <br /> WASTE MANIFEST GAL 0 0 0 1 8 2 6 4 6 1 ( 800) 42419300 018 2 3 3 5 8 2 ) <br /> 5, Generalo 5 Name and t4ating Address Generator's Site Address if( different thae mailing addras,) <br /> JIFFY LU6E tr:_` �'r97 <br /> WESTSACRE IE 4715 N . VVES 1 LANE MONTHLY BILLING <br /> b'dE57 SACRAtrli + N70 CA 9 X691 <br /> CirntataPsflhena: 209 952-:166 2 � STOC ' act1%) Ctt 9521? <br /> 8 Tr�t;ndrturi Contp nyNrm4 U.S. EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2. 7 7 0 3 6 <br /> P : Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address VS. EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5875 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90053 CAD 0 9 7 0 3 0 9 9 3 <br /> Facifit7sPhone: (323)277-3.500 <br /> 9a_ gb. U,S, DOT Description (Indud'ng Proper Shipp§rg Name, Hazard Class, ID Number, 10, Containers 11 , Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No, Type Quantity W1.N01, <br /> 1. NON- RCRA HAZARDOUS WASTE , SOLID , (OILY SOLIDS-PAPER FILTERS) 352 E <br /> DM P <br /> w <br /> i <br /> , <br /> r � <br /> 4 , <br /> it14, Specfaf Handling Inshuctans and Additional information <br /> EMERGENCY CONTACT ' CHEMTREC 1,&800-424-9300 WOES TERMINAL: CERES CS NAERG;# 981 : 1171 'r PROFILE # 961 ; AP <br /> 192210 OILY SOLIDS-PAPER FILTERS * P500-00050605 * APPROPRIATE PERSONAL PROTECTIk EQUIP(i' <br /> is, GEtdERATOR'SlOFFEROR'S CERTIFICATION: i horeby 4erlar? that ihF ovtnntq nt thl.g rnnslnnm:.nt arA fnAy end nmrrately riesrxiN-0 shrive by the. namn, Hr d nra rJassi;ird, pawgod, <br /> marked and laboleddplacarded, and are in all respects in proper condition for transport according to apf�icable international and national governmental reguLitions, if export shipment and I am the Primary <br /> Exporter, i certify that thewnterfls of 6c; consignment arnlonn to Ito terns of the attached EPA Acknowledgment of Consent <br /> I certify that titre :waste midmization statement identified In 40 CFR 26227(a) (if I am a large (wantity generator) or (b) (if Ian a small quantity generator) is truo. <br /> Grin€a{ xst0(fitoes PrinlediT lood forme 5ig4apira Month Day Year <br /> J tfi. f 'a� E. irdnal �a11 'Rt1t5 <br /> lJ(r—�i <br /> j._ impyt to U.S. El Export from U.S. Portot eNr}=!exit: <br /> — Transporter signat:na (tar experts on:y): <br /> Date leaving U,S.: <br /> Lw 17. Transporter Ackro edgrnentofReceiptofMaterials <br /> a Transporter i Print dlTypcd Nama r �r d i'` �� Ylo tth 0� Year <br /> Z Transporter 2 Printed/Typed Name Ssgnv ore !! Month FF Day Year <br /> 1 f <br /> 18. Discrepancy <br /> 18a. Discrepancy Ineiation Space Quantity Type ❑ Residue Partial Rejection Full Rejection <br /> Manliest Reference Number. <br /> 1� 18b. Alternate FecgtykorGeneratort U,S. EPA 10Number <br /> J_ <br /> t3 <br /> LL r ici itys Phone: - <br /> Irte. Snjri ' rig of rYnarr db F cdity (or Garreirrtot) 14Onth Dry ` y nr <br /> 1S. Hazardous Waste Report tai e;ngentcftt Msthod Cedes (i.e „ cedes for hazardous waste treatment, disposal. and recycling systems) <br /> rn� <br /> 1 . 21 3. 4. <br /> 1 - J <br /> 20. Designated Facility Ovmer or O"menperator: Certification of receipt cfhazard-sus materials covered by ilia manifest exupt as noted in Item 18a <br /> Pdnie7j yped Name Signature # xloeb Day Year <br /> Y i <br /> EPN Form 87Q0 22 (Rev. 3 05} Previous ed {(ons are obsolete. DESIGNATED FACILITY TO DIESTINATION STATE (IF REQUIRED ) <br />