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Please print or type-[Farm designed for use on elite(12-pkh)ty ewrlter.) Form Approved.OMB No.2050-0039 <br /> UNI�1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.fUianifest Tracking Number <br /> HA=ZARDOUS C AD 0 2 8 2 7 7 0 3 E 1 (800)42A-930(1, 017 6 96035 JJ!( <br /> Wpyo��� <br /> 5.Go n6€E'N- Uf�fNi E f ITAL SE RVICES GenaratDft Site Address[If different than mailing address) <br /> 1300 S SANTA FE AVE <br /> CC)MiPT01I C J077 i <br /> 310) 886-2400 <br /> Generator's Phone: <br /> 6.Transporter 1 loam N U.S.EPA ID Number <br /> VJOI�LDDiL EfJVIRONPiIENTALSERVICES 7 t U 3 <br /> 7.Transporler 2 Company Name U.S.EPA ID NurnbeF <br /> &Desoaled Facility Name and S}teAddress U.S.EPA ID Number <br /> ASBURY ENViRONMENul-SERVICE-CERES <br /> 1920 NIIOR(GAN RD, <br /> CERES CA 95353 <br /> Facility's Phone: (209)541-1825 <br /> ga 9b.U.S.DOT Description(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. TypB Quantity Wt.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL 33 <br /> SOLUTIONS) n <br /> 001 TT <br /> z 2. <br /> w <br /> C7 <br /> i <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT CHEIV)TREC 1-800-424-930: NOES TERfVIINAL UNION CITY CS ''.APPRORIATE PERSONAL PRO'i C'i IVE <br /> EQUIPhAENT*ENIERGENCY CONTACT Ch. ,t I REC 800 424 9300 "TRLICK#_ mtwl <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 labeled/placarded,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 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)JJk1 am a small quantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Sigv2 <br /> Month Day Year <br /> C91 311 1 <br /> J 16.International Shipments <br /> t= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinledlTypad NnmeILL <br /> Month Day 3r <br /> S b 1 3! 1 <br /> QTransporter 2 PrinladrTyped Name Slgnatura Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generafor) U.S.EPA ID Number <br /> J <br /> U <br /> rai Fadlily's Phone: <br /> 18c.Signature of Altemala Facllily(or Generals,r) Moth Day Year <br /> d <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 13. 4. <br /> AA IL ` <br /> 20.Designated Facility Owner or Operalor:Certification of receipt of hazardous materials covered by the manifestamr as noted in Item 18a <br /> PrintedlTyped Nome Signature Month Day Year <br /> N�Lvvt <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />