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®93047-16 ,DTA 1l@_ 66. 0077 �` �� -G��Qyy / -7 2336962 <br /> Pleaseprint or type.(Form desigeed for use'on elite'12-phch ewntec U� -d? D-7ro / I Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenerdtorlD Number 2.Page 1 of 3.Emergency Response Phone 14.Manliest InImn Number <br /> WASTE MANIFEST 'CRL0004y13752 1 (877) 577-2669 OO 01 9 3 89 DAT <br /> 5.Generators Name and Mating Address Generator's Sita Address(if different than mailing address) <br /> 'ASRohn Services Sunit Was Services <br /> 705 Indsstriai Park Drive 105 IDdastrial Park Drive <br /> Generator's Phone: Padua CA 95337 (1891815-3041 fiaDtoea CA 95337 .(299)025-3041 <br /> 6.Transporter 1 Company Name U.S.FPA ID Number <br /> 21st Centur'v Environmental flanaaeoent of California. LP CAR000210617 <br /> 7 nsporter 2 Company Name U.S.EPA IDNumber <br /> -TX �Gcc. G SU <br /> 8.Designated Facility Name and.5doAddress U.S.EPA ID Number <br /> 21ST CUNT EINIRBS(MIRL 11A.Y SBUT OF IgYW LL9 <br /> 2895 AE(1P.1®S DRIVE EAST <br /> Facilltys Phone: FEMIFY, KV 89488 (875) 575-274U NVD9130995338 <br /> gra 9b.U.S.DOT Desaiptiori'(ndud'ng Paper Shipping Name,Hazard Class,ID Number, 10.Come!M 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WlNol. <br /> 1" UIU991 BETE F!(M19,E LIQUIDS, N.G.S. 1111WAk SPI4ITS, D001 DD16 F803 <br /> 0 X 6BSBILBE) D tial 90(1801_IYSUS) DPI ;p P 214 <br /> w H <br /> Z 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> (1) 7S3722-11 ERn111211 RIkED SBLYE)TfS <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contends of this consignment are fully and accurately described above by the proper shipping narye,and are dassifad,packaged, <br /> marked and abeledlplacarded,and are in all aspects in proper condition for transport according to applicable International and national govemmental regulations,d export shipment and I am he Primary <br /> Exporter,I autity that he contents of his consignment conform to the terms of the attached EPAAdarowledgment of Consent. <br /> I certify that he waste mmannizatien statement identified in 40 CFR 262.27(x)(d I am a large quantity generator)or(b)if I am a small quantity generamr)is true. <br /> GeneralordOIferor's PrnledrTyped Name Signature Month Day Year <br /> I <br /> 103 149 / <br /> -1 16,InternationalShipments <br /> 2 ElImportto U.S. ❑Ex <br /> ; pfaro U.& <br /> faU.S. Pon of; Iexa: <br /> Tmnsportersignatum(for eaports only): Date Is gU. <br /> W 17.TmnspoderA6uomedgoant of Receipt of Matedals I <br /> Transporter 1 Pdnledrryped Na^� _ Skg are - Month Day Year <br /> ©hh 5o� 3I 191 l <br /> Q Transporter 2 Printed/TName SgnaNa // Month Day Year <br /> pe <br /> 18.Discrepancy ' <br /> 1 18a.Discrepancy Indication Space` <br /> ❑ Quantity '❑Type ❑Residue ❑Padial Rejection El Full Rejection <br /> Merriest Reference Number <br /> 18b.Akemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL FacT4ys Phone: <br /> w 78c.SignaNreofAgemate Facility(a Generator) MonthDay Year <br /> Q <br /> Z <br /> CD 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous naso treabnent disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by he manifest empt as noted in Item tae _ - <br /> PH edlTyped Name SignatureMonth Day Year <br /> N (1 _ <br /> 71 t(r <br /> EPA Form 8704 "(Rev. 5) Previous editions are obsolete. DESIGNATE ATORSTATE(IFREOUIRED) <br /> 12350.17481R' Z 2 2016 <br />