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0 0 <br /> Please print or typo,(Form designed forum on elile(12-pi1cN)typewn!erJ Form Apprond.OMB No.2050-00319 <br /> UNIFORMNAZARDOUS LGenua!or10 N5xnber 2.Page lot 3.Emerpmay Response Phone 4.Manlfesl Lack pNomber <br /> WASTE MANIFEST 11 A L 0 0 0 7.s 8 3 7 5 1 (8001 ata-9300 012426134 JJ K <br /> b.Generalots Name and hmdirgAddress GenemWSSToAddres9(IdAlarenl man ma.Nng address) <br /> PICK N PULL#80 <br /> 2927 CLARK DR 3927 CLARK OR <br /> STOCKTON CA 95205 STOCKTON CA 95205 <br /> Genaaiods Trim: 010 669-2000 <br /> 8.Transporters Company Name <br /> U.S.EPAID N4mber j <br /> ASBURY ENVIRONMENTAL SERVICES A D 0 2 8 2 7 7 0 3 6 <br /> I.Trenspoder 2 Compa yName <br /> US.EPAIO Number <br /> 8.DenegwkdFaonly Name andSiteAddress U.S.EPAIDNwtber <br /> OK DIXON <br /> 7300 CHEVRON WAY I <br /> DIXON CA 95620 <br /> Faaktya Phone: (707)692 41008 'A T 0 6 0 01 2 6 0 2 � <br /> 9a. 9b.U.3.00T0"llonjindudrg Proper Sh!pprgName,Ilwam Class,IDNunYaer, 10.Conlamem Ii.low 12.Un1 I <br /> HM end PacsirgGroupglany)) No. Tv" Owaay WI/vol.- 13.WasteCodes i <br /> INON RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL 00i T G 133 <br /> o SOLUTIONS) <br /> I ! <br /> J <br /> a. <br /> 14. pedal HamYnp lnalnrttgns aolAddxaW Umrmal'm I I <br /> NAERGN 961:171* PROFILE#9Bi:DK100i83***EMERGENCY CONTACT:CHEMTREC 1-800.4249300 <br /> ADDITIONAL EPA CODES:9Bi:,NONE*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> U i <br /> 15. OENERATOR'SIOFFEROR'S CERTIFICATION:IImnbydeetamUal anlenleofPdsmstignmemare(any and auurale,Ydeunbed shove by Ue pmpershppnq mama,sof as UassP.cd,passaged, <br /> mmked and hbeWli!acarded,andareh anrespecls in pmper cond8on For transport according to appacaNe IntematonalaM national goremnaedal regulaLons.Yexpanah'pmenlaM I am IhePfunary <br /> Expodez,I eerety Ual tie cadenlselDes<onigrmenl eenfmm IOUo terms alUp a0achcd EPAAdms;edgmenlalConsenl. <br /> l ud4y Ual Uawasm naa�evza4anslalemMlMmGfedindOCFR 2622T(a)(dlamalarye Wanhygeneramr)or(b)(plamasma'd qu eialar)Is , <br /> Gerenalots:08erod yped Nam Sg,ulure Meeh Day Year <br /> ( 1 <br /> 18.Inierwdowl nls <br /> ~ Z' <br /> p.. ❑Importm UB. LJ E. frgn Porloi entryiexil: ( <br /> Y Transpatea sgnxmre(for expols mny): Danleavog Us: 1 <br /> 17.Trans poderAcknonzdgreen! ReceptefMaledds <br /> Transporter PnmeNTyped ams SignaNre A'anU Day Year <br /> j Tro r P !ed/Flped ams a 1.lonU Oat lfea7 <br /> Ciscs"ancy <br /> t tea.Dsuepaney lrekaeon space ❑ ntiy ❑per ❑Revdue ❑ParGelfle;ectlon ❑Fu7 Reaction <br /> Names!Re emnco Number. <br /> 18b.ARernate Teary far Germa!or) U.S.EPAIDNumber <br /> U <br /> u Faaiys Phone: <br /> w 18c 5gnomredNterrum fadiy(a Genera!a) Month tray Year <br /> 4 <br /> 19.Hazardous Waste Report M1ffiugeimnll.!elhod Codes as..codes mr hazalloesweem bealmen4disposas,and recycangsys!ems) <br /> p 1. a 2. - 3 T. <br /> 20.Desgwled FaaStyOhmar a Opnamr.CergEcaCnnofrecoplufImmelws materials covered by due manifest except as InIlem IOn <br /> ams Sgramre I Day <br /> o n' ��� <br /> FPA Form utuo-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILIT TO DESTINATION STATE(IF REQUIR O) <br />