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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 of3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 3 5 8 9 7 3 1800) X124-9300 0 09 <br /> 893791 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> TRACY SHELL <br /> 1040 N. BENSON AV RADC ENTERPRISE 3726 N. TRACY BLVD <br /> UPLAND CA 91766 TRACY CA 95W4 <br /> Generators Phone: 2W 83&76M <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> t <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 C A D 0 9 7 0 3 0 9 9 3 <br /> Facilitys Phone: 03231277-1500 <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(if any)) No. Type Quantity WI-Nol. <br /> 1. 352 <br /> NON-RCRA HAZARDOUS WASTE, SOLID (OILY SOLIDS) D m 201) P <br /> z 2. <br /> w <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT: CHEMfREC 1-600-424-9300 NAERG#9B1 : 171 *PROFILE#9131 AP191624 OILY SOLIDS'PODS <br /> A110152837"APPROPRIATE PERSONAL PROTECTIVE EQUIP\+ENT }_� I <br /> 1 L i 7k/9Z- <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ar classified,packaged, <br /> marked and Iabeledfplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimiza0on statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)orb it I am a small quantity generator)is true. <br /> Genera rs Printedrryped Na e D Sign a Month Day /Year <br /> i <br /> 16.International Shipmerffs <br /> ❑Import to U.S. Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Print ed Na�e Signature Month Day Year <br /> UA <br /> I (iR1 g a� S .r 0.1 a <br /> QTransporter 2 Pdntedffyped Name Signatur Month Day Year <br /> tY <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El 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 /> LU 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Wa to Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and reading systems) <br /> a 2.V <br /> \N\-,\\ I r <br /> 17 <br /> 20.Designated iffy Owner or 0erator.Certification of receipt hazardous modnjcovered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature Month Day Year <br /> EPA form 8700-22(Rev.3-0 Previous editions are ob et . DESIGNATED FAC ITY TO DEST ATION STATE (IF REQUIRED) <br /> 11241.0617 <br />