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Please print or type. Farm designed for use on aide(12-pitch)typevaiter. - Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page td 3.Emergenq Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A D 9 8 2 3 5 6 9 6 1 1 900) 474-9300 008138016 JJ K 5.Generatols Name and Meting Address GeneraWs Site Address(it dMerent than mailing address) M4XlMCR"WOM PO BOX 999 �WRN OSA ROADCA 96206 LA POR TX 71572 Generator's Phone AIR kr12_398i e.Transporter 1 Company Name U.S.EPA ID Number cAOzazTTa3f� AM IRV RmRoNhiIENTAL SERVICES 7.Transporter 2 Company Name US.EPAIDnNUmber 8.Designated pacify Name and Site Address U.S.EPA ID Number, I SIEhfNS INDUSTRY.INC 6376 SOUTH BOYLE AVENUE C A D 0 9 7 0 3 0 9 9 3 LOS-ANGELES _ CA 90058 FadIINs Phone: - (i ga 9b.U.S.DOT Description(induding Proper Shipping Name.Hazard Class,ID Number, 10.Consumers 11.Total 12.Unit 13.Waste Codes €. HM and Peeling Group(if any)) 140, Type Quantity WlNol. 352 K - NON.RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) 3 D M �v p z 2. r'7 3. 4. 14.Spedal handling lnstmctions and Additional information . 7 0 EMERGENCY CONTACT CHEMTREC 1800-424-9300 NAEROi1 91 P40HLE Mi '.AP IOI 159 OILY SOLIDS, ABSORBENT,SWEEP`PO#A110140944'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT NI 3 5-3 y&3 3x SS 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare Mat the contents of this consignment are fully and aoaretely derier above by the proper shipping name,and are classit packaged, marked and labeWplacarded,and are in all respects In proper conWtion for transport awarding to applicable interna conal and natural governmental regulations.If export Allotment and l am the Primary Exporka,I certify that the contents of this consignment conform to dre terms of the at eked EPAAdmaMedgmeM of Consent. I certify that die waste mallmo tion statement identified in 40 CFR 26227(x)(if I am a large quantity generator)or )(lima small quantity generator)is true. s'Olfarces Printed/T Name Si ,^ n Yar M � - � 16.International Shipments ❑Exportfrom U.S. Pod ofenbyleN: ❑Import U.S. z Transporter signature(for exports only): De[a leaving U.S.: ad 17.Trariyoder Achnowledgmem of Receipt of Materials old Tran PnnteNTyped Name Sigrre n ba O ,SL 41 6 2 Tim r2 PrintedR am re - Month D y ear ♦ 18.Discrepancy 189.Discrepancy Intention Spaces ❑ Quantity ❑Type L1 Residue ❑Partial Rejection Full Rejection Manliest Relerenw Number: 18b.Alfemate Faality(w Generator) U.S.EPA ID Number J O sac Fad"Phone: Month Day Year 1&.Sgnatura or Allemale Fadlky(or Generator) 19.Hmrdcus Wasta Report Management Me1Nod Cases 0.e.,codes for hazardous waste treeMenl Disposal and regdirg systems) 1. 2. 3. 4. 20.Dees ,.t,d FadN Omterar 0 Wr:CertMceUon of rewipt o/ thou *ma els covered by the manbel except as noted in m 1 m ams Signature Month Day Year 14 4914� EPAFortn 870022(Rev.3-05) Previous editions are obsolete. DESIGNATE ACIUTY TO D STINATION STATE(IF REQUIRED)