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Form roved.OMB No.2050.0039 <br /> Please print or type.(Form des!gned for use ori chic(12 p€Ich ewdler. ':. <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2:Page 1 of 3,Emergency Response Phone 4. anifest Traekin�pqg Number <br /> 6'8stN� <br /> WASTE MANIFEST G !�0 f3 fl L'3-�" 7 �: (�}"44IC" J. 73 JJ K <br /> 5.Generator's Name and Mall€n Address Generators Site Address(if different than malting address) <br /> Rei' �t9 <br /> 201 E ORCMARD 5fREFC <br /> EI tM1 iQl4i hl" �! 4 i} 37 1401SO[YrI•I C:€�EI'�O4CI±F::AN <br /> Gsnaralar's Phone: 365365-0176 L601 <br /> 6:7rans0arter1Company,Name _ U.S.EPA ID Numirer <br /> :Ik <br /> KP.0 FINITAL 8tdR►1 A O d.2.8 2"7:1.0 3 G' <br /> 7",;lransporter 2 Company Name. U.S.>PA ID Number <br /> 8,Designated Facility Name and Silo Address --U.S.EPA ID Number <br /> J.BrA Mt;ROAN RD. <br /> GERES CA 9635I <br /> CAI.O0 0 8w <br /> Facitilys Phone: ,541.1825 <br /> go. gb.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1f.Total 12,Un tt 13.Waste Codes <br /> HM and Packing Group(if airy)) No. Type Quantity Wt.Nolt _ <br /> t,lyOlI-€ICRA HAMDOUS WASTE,LIQUID(C}II.,Y WATER) 223 <br /> � 2 <br /> ua <br /> s. Asbury Envjanmental.Servic@s^Ceres <br /> has•the at1PWPriatiii,Permi0 to <br /> receive ygiiX• etag <br /> .heivour'wuste , <br /> 680 <br /> 4. <br /> 14,Spacial Handling Insiructions and Additional Information <br /> EMERGENCY CY WNTACT :CHEMTHEO � � �?��:3�t��E���1'�I� IAL;G�F#�� �'AV F OPPIA'(F PER,TONAL I M-ITK-(I P' <br /> LQUit MENTri EMERMNOY Ct)NIM;T CHFM RFC 80&42+9300 '' YlRuck' <br /> 15. GENERATORISIOFFE:ROR'S CERTIFICATION: I hereby declare that the contents of this consignmentarg fully and accurately desaibed above by Ihe.properaMpping name,and are dassihed,packaged, . <br /> marked and labeled/plaearded,and are in all respects In proper condition for lranspart according to applicable Inlemationaland national governmental regulations.If export shipment and t am the Primary <br /> Exporter,I certify that the contents of this comignmant conforrri to the terms of the attached EPA AcknovAedgment of Consent, <br /> I cert'lfy that the waste minimlzallon statement Identified in 40 CFR 262.27(a)(if I am a large quanlitygenerator)or(b)(6I am a small quantity generator)Is true. <br /> Generate offerors Pdntedi ed NameSig nature Month Day Year- <br /> -r 16,International Shipments �b <br /> r ❑import tc U,S, ❑4M from U.S. Port eanlrylexil; _- f <br /> z <br /> Transporter signature for exports only. Date leaving U'S.: <br /> Oi 17.Transporter Acknovlledgmentof Rocolpl of Materials <br /> Tra der 1 Prinled%ped N,a o SIM ure r <br /> Montan a Year" <br /> aTransporter2Pdnledffyped Name Signalure / / Month Day Year <br /> 18,Discrepancy <br /> II is <br /> 18a,Discrepancy Indication Space El Quantity ❑type ❑Residue ❑Penial Rejection iJ Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facllily(or Generator) U.S.EPA ID Number <br /> c� <br /> Facility's Phone: Month Day Year <br /> W 18c.SignaturaofAtlemataFacllity(orGeneWor) <br /> Q <br /> RlZ <br /> �? a ort Management Method Codes Isi codes for hazardorts waste treatment,disposal,and recycling systems) <br /> dons Waste R <br /> 19.Hazer ( <br /> P 9 <br /> to 2, 3, 4• <br /> f. <br /> 20.Designated Facility Owner or Operator:Cartlficatlon of recelpt of hazardous.matedals covered by.lhe manifest except q noted in Itei <br /> Printed ype ame <br /> Sign alure / Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. i= DESIGNATED FACILITY TOGENERATOR <br />