Laserfiche WebLink
Please print or tpo,(Form des( nod for use on elite Form Approvad.00 No.2050-0039 <br /> i.Generall>r 111 Nulubar 21 Page 1 of 3,rnmiganvy Roporiv.Phone 4,manNest 1mviv or <br /> 7 <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST CAI- 000230423 017468610 JJK <br /> Ge4effitoes 1;116Address(d'dftent than maillng address) <br /> t:400 iki`0 FILA%A VVAY <br /> CA 91F'3041 <br /> IN' <br /> 61 11)5 <br /> Genefalor's Phone: nrt => '" 4 <br /> 6,Tmitprier I Gornp4ay Name IJ,&EPA 0 Number <br /> 7 <br /> M FAVI RONNIENJAL 8�MVK;1-,'S 2 <br /> 7.Transporter 2 Company Name U,S,EPA ID Number <br /> 4,Designated Facility Name kind Site Address U.S,EPA 10 Number <br /> US ECOLOGY VERNON M <br /> 6375 SOUTH BOYLE AVENUE <br /> LOS ANGELES) GA 90053 <br /> Facility's phone: t`3231277-15QQ <br /> 9a. 9b,U.S.DOT Description(Including Proper Shipping Name',HVaM Class,ID Number, 10.Corittal ars 11_Total12.UA 13,Waste Codes <br /> HM and Packing Group([f any)) No. Type Quantity, Wt.Nol. <br /> "NON-RGRA HAZARDOUS YEA Ti St.AJD(BRAKE LATHE SHA` IN"33s) <br /> P <br /> 0 <br /> 4, <br /> FIVIFRGENGY CONTACT CHEMM-0, 1-8(30.424-9300 WOES TERNHNALNAERG49SA 171 PROFILE#9611 601528 <br /> MAKE LATHE SHAVINGS F`50&00064362 k APPROPRIATE PPF EQUIPM E <br /> ATAll <br /> -7 <br /> +Z-2 <br /> 15. 0ENERATDR'$1OFF6ROfVS CERTIFICATION: thereby declare that the contents of this consignment are fully and accurale[y daspibed above by the proper Olppmg name,and are classified,packaged, <br /> markud and labolaplacarded,and are In all respects In proper condilion fGr1ransport according to applicable International and nalional governmental fegulaffons.If export shipment and I am the Primary <br /> Exporter,I ccrtlfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement idenillied In 40 CFR 962.27(a)(if I am a large quantity generator)or(b)'(41 am a s 01 quantity maMiotj Is true <br /> 3z:t1oNOffero1rAnied1.Td Name in re Morph Day Year <br /> 7 <br /> "I E <br /> 0,YI <br /> Ll Import to U.S. LlExport from U.S. Port of entryloxit: <br /> 'M Tiansporter slgIrr*re(tor oxorls only): Date h;raving U,8,; <br /> W 17.TransportetAcX"rfttdUmpnI.of Receipt JMalolliat% <br /> LU <br /> t2 Transporter I P tvpw Namo Signature M—WA Day Year. <br /> 0 V1 I <br /> Jx. <br /> Z <br /> (n Transporter 2 Pri fafted Name Signature Month Day Year <br /> F- <br /> 9 <br /> Ia.Discrepancy <br /> 18a,Discrepancy indication Space <br /> El Quantity El Type F—]Resldue Fj Partial Rejection ❑Full Rejection 11 <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U,S.EPA 10 Number <br /> Farlillyrs.Phone: <br /> U, 16c.Signatu <br /> re,of ARernato Facility(of Generator) Month Day Year <br /> CS2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 01, 4 )q I L <br /> 20,VesignatedfMilp*neror Operot Gertificallon of receipt of hazardous materials covered by the manifest except As ndisd in Item 16a <br /> Pr IXYTypod Nony f <br /> 1121 <br /> rPA.Form 8100.2211ev.3-04) Prev!oiis editions are obsolete. DESIGNATED FACILITY TQ�DESTWLICON STATE(IF REQUIRED) <br />