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i <br /> a <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OM8 No.2050-0039 E <br /> UNIFORAIFIAZARDOUS 1-GenetalorlDNumber 2.Page tof 3.Emergency Response Phone 4 A<an"sfTracking Number <br /> WASTE MANIFEST C A L G 0 0 3 3 0 4 2 3 1 8405 +4249300 016774132 JJ K <br /> 5.Gemralor's Name and Maiing Address Generator's 5ite Address(ifddferem than smiling address) <br /> TRACY CHEVROLET-Q&M INC <br /> 3400-AUTO PLAZA WAY <br /> TRACY CA 95344 I' <br /> Generators Phone: 2098354500 <br /> 8.Transputer 1 Company Name U.S,EPA ID Number E3. <br /> ASBURY ENVIRONMENTAL SERVICES C AD 0 2 8 2 7 7 0 3 6 <br /> 7,Transporter 2 Gpmpany Name U.S,EPA ID Number <br /> 8.Designated Fadiity Name and Sita Address U.S.EPAID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 9005a C R C}O 9 7 tl 8 0 S S 3 <br /> Fac $Phone: (323)217�11 5W <br /> ga_ 9b.U.S.DOT Description(inducting Proper Shipping Name,Kazatd Class,ID Number, 10.Containers 11.Total 12.ltnil 13.Waste Lades <br /> HM and Pecking Group(if any)) No. Type Quantity V4tNd. <br /> 1 NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) a <br /> DM P <br /> LU <br /> r�1 2. <br /> C7 ........... <br /> .. <br /> 3 <br /> E , <br /> r <br /> 14.Special Handiing lnstruckns and Additional Information lO <br /> EMERGENCY CONTACT:CHEMTREC 1-8004249300 NAERGO 9B1:171 *PROFILE#951:AP191625 OILY SOU IDS w / <br /> P50040043437 *APPROPRIATE PERSONAL PROTECTNE EQUIPMENT <br /> 15. GENERATOIt'$IOFFEROR'$U"FICATION: I hereby dedare that the conferts of this ocnslgnment are fuly and accuralaiy dwribed above by the proper shipping name,and are Classified,packaged, <br /> marked and Iaf etedlplawmW,and are in all respects in proper Condition far transport acmming to applicable intemalkxW And national govemmerdai ragulatians.If export shipment and I am the Primary <br /> E*onor,I certify hat the eontenis of this consgnmsntmnform to the terms of the attached EPAAcknoMedpoal of C rwAmE <br /> I Certify that Iha Waste mint! in 40 CFR 42.27(a)VI am a targe quantity germmtor)or(b)[rf I am a small quantity generator)fS hue. <br /> e atar'af _ yped flame Manch Ray Year <br /> 1S.IntamatiorW Shipments <br /> i— ❑Import to U.S. ❑ U.S. of antrylexit <br /> z Transporter signawra(for e)Wt only): Date reaving U.S.: <br /> 17.TransporWAdvwvledgment of Receipt dMateriaN <br /> Uj <br /> a Tia s iter t Pdn Name Signature MonthQ D77ay Year <br /> a <br /> ! G <br /> Trans rter 2 Pdofedflkpad Name Si natu Month Day Year <br /> c <br /> t- <br /> 18.Discrepancy ❑ <br /> 180.Qisaepancy Indication Space Elquantity Type ❑Residue ❑Partial Rejection ❑l=ull Rejedion <br /> �E. <br /> Manifest Rafarence Number. _ <br /> I9b.Alternate fadI4(o(Generator) U.S.EPA ID Number 3i <br /> 3, <br /> J li <br /> La <br /> FarAitys Phone; <br /> 18c.5{gnature AllemateFadlily(orGeneraivr) 1rai Day Year <br /> 19.Haryyardmm Waste Report Management Mebod Codes(i.e_Codes for hazardoW waste treatment,disposal,and racyding syslems) <br /> LLI a I�t 2. a, 4. <br /> 2D,Designated Facigy Owner or Operator:Certificatloft of receipt of hazardous matodais Coverad by the mahffest except as noted in Item 18a <br /> J1nnWVTypd Name Signature Month Day Year <br /> E orin 8700-22(Rev.315) Provl4us tt,tions are absdato, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> k <br /> F <br /> i <br />