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Please print or type. (Form designed for Use on elite (12 pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br />Generator ID Number 4. M'� <br />2. Pagel of 3. Emergency Response Phone Fffamlost Tracking Number <br />rj , <br />Manifest ��- I ,. — e, I <br />UNIFORM HAZARI)OUS 11 1 11 <br />EPA Form 8700-Z2 (R&. 3-U5) Previous editions are obsolete. DESIGWATED FACILITY TO C. Ea STATE (IF REQUIRED) <br />N <br />'A <br />WASTE MANIFEST <br />ch-Ftwo <br />0 0 0162D <br />' �) JJK <br />5. Generator's Name and ;Mall Address Generator's Site Address (if different than mailing address) <br />X1 FFY LIJ51RIE , <br />-111,30 N. iWAN $T 111,10 N MAIN ST <br />F-11WErDA MWITE. G A <br />Generator's Phone: `109 N -f M <br />6. Transporter I Company Name U.S. EPA ID Number <br />ASBURY EMAR(WWNRAL "�, R)ACIES ICAD0282770-36 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />,MUS ENVIRMMNTAL <br />R <br />16116'GOOAD <br />ST C4UTH,09ARIVERNENT <br />0, CA 9"1 C A 0 0. 4 0 05 6 <br />Qiff*71_51-47 I <br />Facility's Phone: <br />98. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />W. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />wt.fvol. <br />0 <br />INKON-RURAIAPQ D(YUS WASTE,LIQUID (OILY whin'TEs') <br />V, 01 <br />TT <br />Z <br />2. <br />LU <br />0 <br />3. <br />4. <br />747Special Handling instructions and Additional Information <br />15. GENERATOR'S/OFFEROR'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, <br />marked and labeledlpfacarded, 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 EPAAcknowledgment of Consent. <br />I ceiiffy that the waste minimization statement Idenfifled In 40 CFR 26227(a) (if I am a large quantitygererator) or (b) (if I a -small quantity generai�r) is true. <br />, GbngQt&s/Off9ror`s tedIT" Name 'Stature Month Day Year, <br />r.j <br />F_ <br />16. International Sjhfpments <br />0 Import to U.S. ❑ Export from V.S. Port of an <br />J& <br />I Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter I Pr �nqdlryped Name Signature .1_ yytpMonth, Day Year <br />CL <br />Z <br />Transporter 2 PrintediTyped Name Signaturge Month Day- Year <br />18. Discrepancy <br />I <br />18a. Discrepancy Indication Space UQuantity ❑ Type 0 Residue El Partial Rejectl. El Full Rejection <br />ManifestReferenceNumber, <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />XL <br />L <br />Facilkys Phone: <br />C3 <br />LU <br />18c, Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Viaste Repan Management Method Codes (i.e., codes for hazardous waste treatment, cligposal, and recycling systems) <br />LU1 <br />2. <br />3. <br />4. <br />A <br />20. qesiqnated Facility Owner or Operator: Cenir tion of receipt of hazardous materials covered by the Kanifes x*t as noted In Item 1IIA—, <br />Pr Mo th )Day Year., <br />y 11 J_ t <br />JALJ__j <br />EPA Form 8700-Z2 (R&. 3-U5) Previous editions are obsolete. DESIGWATED FACILITY TO C. Ea STATE (IF REQUIRED) <br />N <br />'A <br />