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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Paget of 1 3.Emergency Response Phone 4.Manifest Tracking Number �/ WASTE MANIFEST rl ti iJ i) 0 1 $ ;2 b 4 �� 1 80U! �i St iUQ� 0 0,TO�d-836 J J K 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) W JI F`FY LUIS#2322 E.KETTLE 1M RD. LODI GA 95240 Generator's Phone: 339-JJ" 6.Transporter 1 Company Name U.S.EPA ID Number A.EBUR`Y ENVRONNENTAL SERVICES C A D U 9 2 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number SIEWNS INDUSTRY INC. 5375 SOUTH BOYLE MENUE LOS ANGELES CA 9W,`4� i.. A D Q 9 7 0 3 0 9 9 Facilitys Phone: MrA277-16I ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(d any)) No. Type Quantity Wt.Nol. 0 NON-RCRA HAZARDOUS WMTE,;301-10(OILY SOLIDS) M 2. w C7 3: 4. 14.Special Handling Instructions and Additional Information ENL-PGE-NC Y W i dI AL . u iL4Vh kiLL 1-1900-424-M NAERGO-xi- 10' L-49121' 1A110154021"APPROPRIATE PERSONAL PROTECTIVE EQUPWNT 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, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(If I am a small quantity generator)is true. [CGenerato5 Offerors PdntedlTyped Name Signature �.. Mon 11L Day fYear � J 16.International Shipments I.- ❑import to U.S. ❑Export from,U.S. Port of eptrylexit: - J z Transporter signature(for exports only): D8lq leoing U.S.: W V.TransporterAdmowledgment of Receipt of Materials j Tra� er t Printed/Typed a / +� Signahuue•' / nth) Qp� yam, s'— ZZTr nsporter 2 Pdn 'drr ped Name Siggp ra r Month Day Year � 1 E-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quanti ty 1:1 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone: U0 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.Hazardous W ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Opgrator.Certification of receipt of azardous materials covered by the manifest except as noted in Reny Sa PdntedrTyped Name Signature J;' j' Month Dafy� Year EPA Form 8700-22(Rev.3-0 ) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR