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08-01-12 02:24pm From-D/K CUST01•" SERVICE +3105378386 T-164 P.01/01 F-183 <br /> Fleasa prnt or type.(Form designed for Us&pn elite.(12-04LI'r ry ewrit6r) '— r ?' <br /> Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Numher 2.Page 1 of 3.EmefgOncy Response Phone a,Man fest T7aalr ng Number <br /> WASTE MANIFEST � A,L 0 0 f, �.r�r.Q1 I'd 2 3 I D ..�4 gAba 008133300 JJ K <br /> 5,Genoratofs Name and Malting Address Generawl's Slta Address(If different than mating adores$) <br /> Q&N1 INC DBA TRACY CHEVROLET <br /> W AUTO PLAZA WAY 96X4 <br /> Generator's Phone: **)m 0^19-d. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASSURY ENVIRONNENTAL SERVICES C A D 0 2 8 2 7 7 0 3 , <br /> i.Transporter 2 Company Name U.S.EPA ID Number <br /> 9,Designated Fadllty Name and Silo Addroas U.S.EPA ID Numoar <br /> i7FfVENNO/KERDOON <br /> 20300 NORTH ALAWDA STREET <br /> CONPTON CA 901222 <br /> Faciu 's Phone: n1 } -7 on C A T 0 8 0 '.0 1 3 3 5 2 <br /> ga 9b.U.S.DOT Desoplion(!ncluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.U nt <br /> FIM and Packing Group(If any)) No 17.Waste Codos <br /> Type Qtrantlry N2Na. <br /> 1. <br /> -343 <br /> LIN1203 WASTE OMOLINE,3, Pall 0 0 1 DM -i G <br /> a 2. <br /> Li <br /> ca <br /> I <br /> 4. <br /> 14,Special Handling tnsUuclWs and Additional Information <br /> WRG# 9131 128'PROFILE#961..:_ _WOLINE 'AODITIONAL EPA CODES:991 : NONE`APPROPRIATE _. <br /> PERSONAL PROTECTIVE FQUIPr*NT <br /> 15. GEN ERATOR'sIOFFEROR'S CERTIFICATION:I hereby declare trial the contents of this consignment are holy and accurately described above by the proper snipping nafne,and are cleaeified,packaged, <br /> marked and labeledlplacarded,and are In all respects In proper Condition for transport according to"kabla intemationsl and national governmental raguiatlons.If export shipment and I im the Primary' <br /> Exposer,I certify that Ina contonu of mis conslonrnont conform to the terms of the attached EPAAcknoMledgment of Coo enl. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a larWouanliry generawr)or(b)lift am a small quantity generator)is true. <br /> Genersw(Wonam(,S1`6nted/TypadName Signature Month Day ' Year <br /> M <br /> 6.Internallonal Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of ennylexlt: <br /> TwSporter signature(for exports only): . Date leaving U.S.: <br /> w 17,Transposer Acknowledgment of Rocoipt of Malarials <br /> Transporter 1 PrinteC pea Name signature Monm Oa Yea <br /> ansponer 2 PrinterIfTyped Printed/Typedname Signature Monm Day Year <br /> r, <br /> 18.Discrepancy }� I� <br /> lea.Discrepancy ImIcaGdxt Space ❑ a,anlity Iwl Type <br /> ❑Residue Fi Penial Rejeel!on ❑Full Rejectan <br /> Manifest Reference Nvmber. <br /> 18b.Allernato Facility(or Generator) U.S.EPA ID Numoar <br /> J <br /> U <br /> L&- F3clilry'3 Phone: <br /> 8e. !gr7wo of Al'emste Faullry(or Generator <br /> � Month Day Year <br /> h19,Hazardous Waste Repos Miingemant Mathod Godos(i.e.,codes for hazardous waste treatment.disposal,and recyding systems) <br /> p 1. 2. <br /> 20.oealgnated Facility Owrer or Operator Cardflcation of receipt of nazardous materials covered by the manifest except m noted In:tem lea <br /> W ped Nathe gna Month Dey ear <br /> , WForm ?10 (Rev,3-05) Previous'edition9 1:1601ete. DESIGNATE <br /> M1L,ITYTO GENERATOR S1ATE (IF }REQUIRED)'. . <br /> _'".:"31.`�S:r+.<:;�: �.:r'`ct..._. .. •_.wf.r�__, ,y,..__. �... + si:,< _ .__ ..,.._.._sTs:.•._ �......_. _. <br />