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Please print or type. Form designd for Use Qn ei'Ite(12-pitch)typewriter.) - - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number _ �{(� <br /> WASTE MANIFE5T JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> -.7WER <br /> 7710 MURRAY L3RNE <br /> CA 95210 <br /> Generators Phone: ;'C9 X78. 97 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ,-ICES- ' 8277036 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> U;-'ECOLOGY VERNON INC <br /> 5975 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90CAD09 7 030993 <br /> Facility's Phone: r <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13_Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity Wt.lvol. <br /> 1-Nom-RGRA HAZARDOUS WASTE,SOLID(8Oi NDO DIiST/DEBRiS) 352 <br /> Z 2. <br /> LU <br /> - _ <br /> 1'~ <br /> 3. <br /> 4, I <br /> 14.Special Handling Instructions and Additional Information r ti <br /> MERGEINMu-CONTACT:CHEIv T REC 1-800-4249300 WOES TEWINAL:CERES CS NAERG#981 :171 *PROFILE#981: <br /> 620910 9ONDO DUST/DEBRIS w P500000F TM -APPROPRIATE Pia€EQUIP <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classlfted,packaged, <br /> marked and lsbeledlplecarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cefify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certIly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Genarators Offerors <br /> Printed/Typed Name / kigpature �f Month Day Year <br /> -.I 16.International Shipments <br /> El import to U.S. Export from U.S. Port of entryledt <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature -y Month Day Year <br /> 0 a, <br /> 2M[T7T;F97FNedrryped me Signature Month Day Year <br /> H <br /> 16.Discrepancy <br /> 1$a.Discrepancy Indicator Space ❑ Quantity ❑Type ❑Partial Re ❑Full <br /> Residue Rejection Rejection <br /> Manifest Reference Number. <br /> r- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> zi <br /> V <br /> 1 Facility's Phone: <br /> 1=1w 18c.Signature of Alternate Facility(or Generator} Montt€ Day Year <br /> Q <br /> z <br /> Fa19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 20.Designated Faciiity'l7wner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped Name- Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous ediibons are obsolete. DESIGNATED FACILITY TO GENERATOR <br />