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017791238JJK <br /> t <br /> Please print ryF, ,Newrilan� Form Approved.OMB Ko.2l <br /> UNIFORM HAZARDOUSa ID Number 2.Page 1 or 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 7 2 3 1 800 493 017791238 JJ K <br /> 5.Generator's Name and Melling Address Generator's Site Address(d different than malling address) <br /> CERTIFIED COLLISION CENTER <br /> STOCKTON CA 95210 <br /> Generators Phone: 209 830-MO <br /> 6,Transporter I Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Noma U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Nambor <br /> US ECOLOGY VERNON INC ; <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 . CAD 0 9 7 0 3 0 9 9 3_ <br /> Facildo Phone: <br /> ga, 9b.U.S.DOT Descnptidn(mdudvg Proper Shipping Name,Hazard Cass,ID Number, 10.Contalnam 11.Tual 12.Unit 13,Waste Codes <br /> HM and Packing Group(f any)) No. Type Gummy WLftI• <br /> 1.NON-RCRA HAZARDOUS WASTE,SOLID(RONDO DUST) 4 <br /> ` DM P <br /> w <br /> 2. <br /> Ctl <br /> 3. <br /> 4, <br /> 14.Speotai Handling LStrudion4 and Additional Indbimafion <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424.9300 WOES TERMINAL:CERES CS *PROFIll 931:588536 BONDO DUST* <br /> P500-00055228*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 1H 2bn 0 ?�It 5O'Dl- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby doclare that the contents ofthis consignment are fully and accurately described above by the propershippi name,and are daWl!lad,packaged, <br /> marked and labeledlplacarded,and are In all respects In proper eondiGan for transport according to applicable Intemat onaland national governmental regulators.I xportshipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consarrt <br /> I certify that the waste uUmtbIl statement identified In 4D CFR 262 (a){f I am a large quantly generator)or(b)[di am a s an6ly generator]Is Iru. <br /> fiie0pramf Printedlty�ed Nam f �1 Slgna4me Month Day Yey, <br /> 1" = -"/ —-- P9j) <br /> J 16.Intema Tonal Shipments <br /> F ❑Import bU.S. ❑Export from U.S. Pondenbylexlb <br /> x <br /> Transporter signature(for exports only): Date feadmgU.S: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> aTra I r 1 Print ype Name signature Month Oay Yea <br /> a <br /> l� r� <br /> Trarl PnnW#ed Name Signature Month Day Year <br /> 16.Discrepancy <br /> 15a.Discrepancy lndication5pace ❑4uantily ❑Type ❑Residue ❑PartiatAejedloa ❑Fu9Rajecdon <br /> Manifest Reference Number. <br /> 16b.Alternate FacilEy(or Generator) U.S.El Number <br /> C] <br /> tQs. Facilily'sphone: <br /> 18c.5ignatureofkematal liry(orGenerator) Wrb Day Year <br /> to 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment disposal,and recycling systems) <br /> C 1. ] ` 2. 3. 4. <br /> 20.Deslgnated Facility Owner or erator cer9cation of recelpt of hazardous materials covered by the maNiost except as noted in Item 16a <br /> Ll :zv, '4.'. t�� <br /> PdntedrTyped Name 5 rature Mth Day ear <br /> d <br /> EPA Form 671l(Rev, 5)Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />