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017696539JJK Please print or type.(Forth designed for use on elite 02-pitch)typewriter) Form Approved.OMB No,245 0039 UNIFORM HAMDOUS 1-Genemtvr ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManiFest Tracking Number WASTE MANIFEST I c 4 L o 0 0 3 7 12 1 3 1300)424-2300 017696539 JJ K 5-Generators Name and Maili Address Generators Site Address(if different than malting address) CERTIFIED COLL ION CENTER 7710 MURRAY DRIVE S- GCIt7ON CA 9521D Generators Phone: 209 834980G 0.Transporter 1 rr3mpany Name H 5 FPA ID Numtx r WORLD OIL ENVIRONMENTAL SERVICES C A ID G 2 8 G E 7.7ranspcner 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address US EvOLOGY VERNON INC U,S.EPA i D Number 5375 SOUTH BOYLE AVENUE L6ANGELES CA 90058 Facititys Phone: 32312 7 7-1500 C A D G 9 7 G 3 0 9 9 3 9a- 9b.U.S.DOT Descriptior(including Proper5hippmg Name,Hazard Class,ID Number, 10.Containers HM and Paddng G oup(f arryJ) 11,Total 12.Unit 13.Waste Codes No. Type Quantity wt Nd. G 1NON-RGRR HAZARDOUS WASTE.SOLID{BONDi3 DUST} 52 F D M p iF3. _ LU cs I I ' 4. ----------- 14,Special handing instructions and Additional Information E=MERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS *PROFILE#981:588536 BONDU DUST P50"0058712*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 15. GENERATOW&OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fulty and accurate) descrbeo'above the marked and labeled/placarded,and are in all respects in Y by p open shipping name,and are classified•packaged proper condition for transport acoordmg m applicable intemf and nal governmental regulations.if export shipment and I am the Primary Exporter.I certify that the ooments of this consignment conform to Me terms of the attached EPAAUmowladgm aF I certliy Met the waste mininAzation statement identified in 40 CFR 262.27(a)('d I am a large quantity generator b - a GeneratratsPhntedsmall generator)is true- ill Name uan qilly Si Mordh Day Year 16.in Shipments ❑Import to U.S. ? Transporter signature(for exports onlY) ❑ExPO horn U.S. Port cl entrylex t: 5: tu 17.TransportwAdnowledgment of Recotpt of Materials C T nsparter 1"mediI yped Name a S re Month Day Year Z IWFISPorler2PdnWWIyped f4ame Im 10311 IX: -gnaw Day Year 38.Discrepancy 18a,Discrepancy Indication Space ❑Quantity ❑Type LJ Residue ❑Partial Rejection ❑Futl Rejemar 18b.Alternate Facility(or Generator) Man fest Reference Number: U.5.EPA IQ Number LL Facildys Phone: W 18c-Signature of Akmate Facility(ar Generator) Month Day Year N19.H s Waste Report Management Method Codes(i.e..codes Tor hazardous waste treatment,disposal,and recycling systems) w c t. [u 1 z 4. 20.Designated Facility Owner or Operator.Certificareceipt 11 11 t on of of hazardous materials covered by the manifest except as noted in Item 18a PrintoWTyped Name Sign e Mardh Day Year FPAForm 8700-22(Rev.3 05) Previous editions are obsolete. Y{ DESIGNATED FACILFTY TO DE TION STATE REQUIRED)