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Please print or Form designed for use on elite(120tch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAmis 1.GenerWw ID Ntmrber 2.Page 1 of 3.Emergency Responee Phone 4.tkenth9 TraMag NumMr <br /> WASTE MNIFEST I CAL 0 0 0 8 2 7 8 9 2 1 (800 424-9300 16775154 JJ K <br /> 5.G mere6a s Name and Mail%Addnm Generatorh Ste address(8 dmerent thea meiing address) <br /> HOLT OF CALIFORNIA(STOCKTON.) <br /> PO BOX X 1521 CHARTER WAY <br /> SACRAMENTO ner209466 60th CA 95813 STOCKTON CA 95206 <br /> Geators phare: <br /> 8.Transporter 1 Company Name U.S.EPA 8)Number <br /> ASBURY ENVIRONMENTAL SERVICES CAU 0 2 8 2 7 7 0 3 6 <br /> 7.Tranapater 2 Caoparry Marne U.5.EPA ID Number <br /> a.Designated FaorM'y Name and Sib Address U.S.EPA ID Number <br /> US ECOLOGY VERNON, INC. <br /> 5375 SOUTH 80YLE AVENUE <br /> LOSANGELES CA 90058 <br /> FaM es Phone: ($02667747 CAD 0 9 7 0 3 0 9 9 3 <br /> ga. Ob-U.S.DOT Deecaiption{mdodkg Proper Sh`p t Nemo,Hazard Baas,ID Number, 10.Contalrtera tf.Total 12.UnY <br /> HM X19 (dpi)) W. Type Quantity INuw, 13.Waste Corks <br /> ge 1 NON-RCRA HAZARDOUS WASTE,SOLID(PAPER FILTERS) OZ DM p <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handing Insinrdl m and Adchor l Int mUtio, <br /> EMERGENCY CONTACT:CHEMTREC 1.800-424-9300 NAERGN 981:171*PROFILE#9B1; PF ORDER#5500-00 60 <br /> ADDITIONAL EPA CODES:9B1:.NONE x APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT ;7- <br /> c ILI <br /> 15. GENERATOR'>if MIMRI CERIF"TiON:I hereby dadam that the omnia of Sia cmdgwwa are fuly and wouratety described above by the proper sNpptrg name,ardd are dassFed,padoged, <br /> marked and labete4lacarded,and aro n al mspeeN in proper oondidon fa trar>sport aoc«drg b awbcat>ae ntemad W WA national <br /> the ow <br /> EVoriar,I certhy that lerb of this t .H effort sNprnera erd t am gra Primary <br /> mreigrartant aordonn m the farms of the attached EPAAdnlowietfgmeM of <br /> t Cadfy that the waste mir*&gon statement awffied in 40 CFR 26227(a)(N I am a large quantity paneranr)of af(fj&m a smal quw*generator)is t m <br /> seri Marne Mwi Z08 Year <br /> K--X-,O� <br /> mjif l <br /> s• Import U.S. ❑Export from Port of entry/axft <br /> Trenaponer (fa a+IY1: Qak)eevi,g U.S.: <br /> 17.T Ad-Medgmant of Receipt of Ala(arlals <br /> T 2 Name s� Morb Day Year <br /> 18.Dieaepawy <br /> iia.Nwaparq indication Space ❑ r ❑Type ❑Reaidue ❑par8el Rejad}on ❑Ful Re)edlou <br /> Manifest Retarence Number <br /> 18b.Al6srratte Wry(or GonaaOx) U.S.EPA ID Nra+iber <br /> V <br /> W Fac*A phare: <br /> 18C.Signeaao Aroma%Fanny{a nerator) ManBr <br /> Day Year' <br /> '" d"Waste PAPod Management tt 00W Codes 0-C.Codes for hvmdous+caste treah onk disposal,and raiding syMama) <br /> A 1• •( 2• 3. <br /> 4. <br /> 20.DesWAM Fad Ay or Operator•,Certification of receipt of hazardous mabedals wwired by to Manifest except as rKtad kf Mm 183 <br /> R;W�Name ��� Slgnatrae <br /> FPA Form 87W22(Rev.3.05) Previous editions are obsolete. 14A 71 <br /> DESIGNATED FACILI Mrnp ATiON STATE(IF REQUIRED) <br /> I <br />