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Prease print or typk:tF-mTrrtVsicgned for use on elite 12-pitch typevarlter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Ememency ReWra Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �` <br /> r1LC)UOuJOi:_,3 S'00)4114-IJJ;c 7468641 JJK <br /> 5.Gene,atq N t' dCyr•1a ling A41ress}`r _ Generator's Site Address(if different than mailing address) <br /> I_6I rI L�1" VLlit-)IV ) 141E r�E1 L-�I1�� <br /> 301"1 F {H-A1MMER b-%NE <br /> U lJJ Sli7{ <br /> Generator's Phone: <br /> 6,Transporter 1 Com n NWe U.S.EPA ID Nu r: <br /> ti:� t-U >�L�NV0iUfgMENTAL SERVICES C t.U O_'8 2 7 7 0 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ° Designated Fadilty Name aq.0 Silo Address U.S.EPA ID Number <br /> US LL OLOGY VERNON INC <br /> 5375 SOUL H BOYLE AVENUE <br /> LOS ANGELES CA 90053 i-,A u(_i 9 7 G a 9 9 <br /> Facility's Phone: '.,23)277-1500 <br /> 9a. 91b.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.Nol. <br /> 0 <br /> 'NON-RCRA HAZARDOUS WASTE,SOLID(BRAKE LATHE SHAVINGS) <br /> 2 . <br /> 3. <br /> 4 <br /> I <br /> 14,Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 WOES TERMINAL: NAERG#9151 : 171 *PROFILE#9B! ,AP���� <br /> BRAKE LATHE SHAVINGS >,P500-00064771 *APPROPRIATE PPE EQUIPMENT n0 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify 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 /> lorslOfferors PrkrledlTyped Name gn tura Mcnth Day Year <br /> J 16.Intemat anal S ' lents <br /> Z 11 Import to U.S. i..J Export from U.S. Port of entry/exit: - <br /> Transporter signature(far exports only): Date teamm U S <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> O Transporter 1 ore <br /> pod No Signat, Month Day YGar <br /> IL <br /> QTransporter 2 Printedrry d Nama Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j <br /> ❑Residua ❑Partial Rejection Full Re ec8on <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Gormrato-) U-S.EPA ID Number <br /> J <br /> V <br /> Fadilty's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printadfryped No Signature Month Day Yoa, <br /> 06 C °7 al��Gf1(isi JAI <br /> EPA Farm 8700.22( v, -05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTI ATION STATE(IF REQUIRED) <br />