Laserfiche WebLink
Please print or type. ( Form designed for use on elite ( 12- pitch) typewriter. ) Form A pro,�ed . OMB No , 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 . Page 1 of 3. Emergency Response Phone 4, Maniiest Tracking Number <br /> WASTE MANIFEST A i_ J 0 0 L 5 0 0 3 1 ( 300) 13-', • S 00 014 0 514 9 2 JJ K <br /> 5, Gonuralo Nome and M rflirigAddre_= Generator's Site Address (if different than mailing address) <br /> FREI 'IIEF CHR'i'SLER DODGE JEEP RAfi'I OF T P,AC••( - PRE14 ; <br /> 34 :50 iNAGLEE ROAD <br /> ILACY Cr, 95304 <br /> Generator's Phone: 209 820 .1615 <br /> 4. 1rartsporiei 1 Company Name U.S. EPA ID flumber <br /> A,SbUR'f ENVIP, orIr,JEr; T.AL SERVIt, ES C DO 8 77 0 3 6 <br /> 7 Transporter Company Name U.S. EPA ID Number <br /> 8. . Dcsignaled Facility Name and Site Address U,S• EPA ID Number <br /> US ECOLOGY 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 /> 7HM <br /> 9b. U S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit <br /> 13, Waste Codes <br /> andPacking Group (if any)) No, Type Quantity Wt,Nol, <br /> 0 1 NODI- RCP,A HAZARDOUS WASTE ,I.SOLID (OILY SOLIDS , PAPER FILTERS ) 502 I <br /> r <br /> 2 , <br /> 3. I <br /> 4 . <br /> 14 , Special Handling Instructions and Additional Information <br /> Ei ,9ERGENC`( CONTACT : CHEMTREC 1-8004f14-9300 2NAERGn 961 : 1 ; <br /> i ERS 1 PROFILE N 961 : AP200S90 OILY SOLIDS , PAPER <br /> FIL- " P500.0002RSONAL PROTECTIVE E <br /> 6858 APPROPRIATE PERSONAL <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare (hat the contents of [his consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labelediplacarded, and are in all respects in proper condition for transport according to applicable international 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 EPAAcknovdedgment of onsent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity genaraiur) or ( (I I am a small quantity generator) is true. <br /> GeneratoftlOfferor's Printed/Typed Namp ` Sign ro Month Day Year <br /> 0 � /E <br /> —� 16. International Shipments -- <br /> F ❑ Import to U.S, ❑ Export from U , S. Port of entrylexit _ <br /> a Transporter signature (for exports only): Date leaving U.S.: <br /> UW 17. TransporlerAcknowledgmenl of Receipt of Materials <br /> Trans pg1161 PriniedfTyped NameSignature Month Day 'fear <br /> a F .. CGS_ ✓ ✓._-./ 1 � � Cf <br /> QTransporter '2 PrintedlTyped Name `-3 gnature Month Day Year <br /> a <br /> E- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space [:1 quantity ❑ Type ❑ Partial Re El <br /> ❑ Residue Rejection Rejection <br /> Manifest Reference Numher; <br /> 181b. Allem©(e Facility (or Generator) U.S . EPA ID Number <br /> J <br /> U <br /> �+ Facility's Phone : <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19. Hazardous Waste Report Management hlelhed .Codes (i.e., codes for hazardous waste (reaiment, disposal, and recycling systems) <br /> 1 2, <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PhnledfTyped Name Signature Month Day Year <br /> EPA Form d700-22 (Rev. 3.05) Previous editions are obsolete. DESIGi' IXF iD P^, C111TY TO DESi11 , 1T101' 1 STAT E O ` F? H- ce). J ) F; ; -D <br /> i <br /> I <br />