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DTSC. 02362. 2476 <br /> Please print or type.(Form designed for use on elite(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 MANIFEST CAL 0 0 0 3 5$9 7 3 1 (800)424-9300 010853096 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> TRACY SHELL <br /> 1040 N.SEN9DN AV CA RADC ENTERPRIS 3725 N.TRACY BLVD, <br /> UPLAND 9178fi TRACY CA 95304 <br /> Generator's Phone: 209 835-760$ <br /> 6.Transporter 1 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 Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SIEMENS INDUSTRY,INC. <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 097030993 <br /> Facility's Phone: (323)2774500 <br /> 9a. 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(d any)) No. Type Quantity WtNol. <br /> 0 1. NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) 352 <br /> 2 D M I Ob P <br /> ga <br /> Z Z. <br /> LU <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information �7 <br /> EMERGENCY CONTACT:CHEMTREC i-$00 24-9300 NAERG# EB:17i7* ULE#9BI:AP4 9i624 OILY <br /> SOLIDS*P0#A110i62743* APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT r- t S Gq( 1--30 6r <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 labeledtptacarded,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 EPAAckrwwledgment of Consent. <br /> 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 uanbty generator)is true. <br /> Generator'slOfferoes Printed/Typed Name Month Day Year <br /> c.mow• v� v�1 r'J o�-,.�- 2 I I. <br /> 16.Intemational Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> � Transporter 1 Printed/Typed Na e ��� n Signature / Month Day Year <br /> O UAl\ .--.JJ 2 `ft <br /> a <br /> Q CQ <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> L- 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> V519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1, 2. 3. 4. <br /> .17 <br /> 10 <br /> 20.Designated kcil4 Owner or Operat Certification of receipt of h s materials by the man'dest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Pre sous editions are obsolete. DESIGNATED FACILITY TO DESTIN TION STATE(IF REQUIRED) <br /> 11435.2022 <br />