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Please print or type.(Form designed for use co elite(127pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number: 2.Page 1 of 3.Emergency Response Phone 4.Mianifest Tracking Number Illf WASTE MANIFEST CAL 0 0 03 7.,121 w 1 (800)424-0300 017 6 9 6 5 3 9 JJ 5.Generator's Name and Mai{in Address Generators Site Address(if different than mailing address) CERT IrIED COLLISION CENTER 7710 MURRAY DRIVE ST 0 C KT ON CA 9521 0 Generators Phone: 209 830-9300 6.Transporter 1 Company Name U.S.EPA ID Number WORLD OIL ENVIRONMENTAL SERVICES C A D 0 2 S 2 7 7 0 3 6 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number US ECOLOGY VERNON 1N0 5375 SOUTH 60YLE AVENUE LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 FaciQ/s Phone: 432 27 7 15(,0 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity Wuvol. 'NON-RCRA HAZARDOUS WASTE,SOLID(RONDO DUST) 352 � Q i DM F u3 z 12. r E LU r C7 I{ I I e 3. j i t E 4. 14,Special Handling Instructions and Additional information EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS *PRORLE#961:588536 60NDO DUST� P500-00058712 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 15. GENERATOWVOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratefy clesed above by the proper shipping name,.ard are classified,packaged, marked and labeled/placarded,and are in al[respects in proper condition for transport according to applicable intematio f and n ti nal governmental regulations,if export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmen of Ce'P I certify that the waste minimization statement identified in 40 CFR 262.27(a)[f I am a large quantity generator b) a small quantity generator)is true. Generato rors PrinteciTyped Name Sig e Month Day Year iPICZ 11A -j 16.IntomationalShipments rtiromU.S. Poriofen xit F- ❑import to U.S. El 6cpo try!e Z Transporter signature(far exports only): eEu 17,TransperterAclmoMedgmentofReceiptofMaterials - OTransporter-IPnated/Typed Name Si re - Month �Dgay Year 4/� �/ -Z Transporter 2 Printed/Typed Name ignature Mo Day Year 18.Discrepancy 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. t� 18b.Altemate Facility(or Generator) U.S.EPA IQ Number U Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year t-- 4 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) n 1. 2. 3. 4. EDeed Facility Owner or Operator.Cedification of receipt of hazardous materials covered by the manifest except as noted in Item 380- d Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)