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• L' t V J i V l 4-: <br /> Please print or type.(Farm designed for use on elite.(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 4 0 7 8 9 5 1 (800)424-9300 014054405 J J K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> WEST VALLEY AUTO SERVICE LLC <br /> 2615 W GRANTLINE RD <br /> TRACY 95304 <br /> Generators Phone: 209 8363464 <br /> 6.Transporter 1 ComppanyY Name U.S.EPA ID Number <br /> ASBURYtNVIRONMENTALSERVICES - o '� � � � CAD028277036 <br /> 7.Transponar 2 Company Name .. _ _'. U.S.EPA ID Number <br /> 8.Designated Fadlity Name and Site Address - U.S.EPA ID Number <br /> DEMENNO/KERDOON <br /> 2000 N.ALAMEDA STREETF NTAL <br /> COMPTON CA 90222 EMf)R(- CAT 080013352 <br /> Faidlit IsPhone: 310}537-7100 <br /> So. go.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouanmy Wt./Vol. <br /> 1. UN1933,WASTE FLAMMABLE LIQUIDS,N.O.S.,(GASOLINE,DIESEL). D003 D016 343 <br /> 0 3, PGIII f D 5•�j G <br /> z z. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling lnsWdions and Additional Information _ <br /> EMERGENCY CONTACT:CHEMTREC 1.800-424-9300 *PROFILE 8 9B1:0412166 GASOLINE AND DIESEL* *APPROPRIATE <br /> PERSONAL PROTECTIVE EQUIPMENT J e!C' -' <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Wily and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlylacerded.and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If upon shipment and I am the Primary <br /> Exporter,)certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify,that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)21 am a small A242 or)is mill. <br /> retorslOfferors Pnn��ad Nam �, <br /> igna <br /> SWre Monts Day Year <br /> 16.International Shipments ❑import to U.S. by <br /> -u ❑Export from U.S. Pon of en IexiC <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> SM�onth(�/ Day Year <br /> ignaWre t/ T <br /> Transporter 1 Pon yped Name /S 1 L <br /> O V <br /> z Transpoliat 2 PrintedRyped Name Signature Month Day Year <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spam ❑ Quantity Type ElResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> sat w Fade: <br /> Monty —6—ay—Year <br /> 18ckygPacAtemateFadityorGenerator) <br /> zz <br /> L5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,andreryding systems) <br /> W 1 O 2 3 4. <br /> 0 <br /> 20.Designated Facility Owner or Operator:Cer ifiation of receipt of hazardous materials covered by the manifest except as noted in It <br /> 1 PramedlTyped Name Signature Month Day Year <br /> Glyn o W I h4 IIILO <br /> EPA Form 87Do-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY NATION STATE(IF REQUIRED) <br /> 12291.2242 <br />