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4 F A= P <br /> V+ T <br /> V r• A V v r l F, I•� <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 C A L 0 0 0 3 5 8 9 7 3 800) 424-9300 008142902 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> TRACY SHELL <br /> RADC ENTERPRISES <br /> TERPRISES 1040 N. BENSON AV 3726N. TRACY BLV <br /> UPLANDCA 91786 TRACY CA MM4 <br /> Generator's Phone: 209 836-7608 <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 /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SIEMENS WATER TECHNOLOGIES CORP. <br /> 6376 SOUTH BOYLE AVENUE C A DO 9 7 0 3 0 9 9 3 <br /> LOS ANGELESCA 90058 <br /> Facilitys Phone: 77-1500•- <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtIvol. 13.Waste Codes <br /> 1. 352 <br /> NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) r� DM ISE) P <br /> z 2. <br /> w <br /> t7 <br /> t., <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMIREC 14M424-9300 NAERG#9B1 : 171M'PROFILE#981 :42911 OILY SOLIDS'PO# <br /> A110134867'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT /1/' / 9/0 <br /> 15. GENERATOR'S/OFFEROR-S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classKed,packaged, <br /> marked and labeled/placarded,and are in an respects in proper condition for transport accordng 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 minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(fl am a small quantity generator)is true. <br /> Generator slOfferofs Printedlfyped Name Signature Month Day Year <br /> _jI.l e-1564- 5EC4e1V1,H - Of OLf 1.1 <br /> -J 16.International Shipments <br /> t` ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowiedgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signature r <br /> IL CV <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Full Re <br /> ❑Residue ❑Partici Rejection Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J ' <br /> U �r <br /> Facility's Phone: <br /> w 18c.Signature of Atemale Facility(or Generator) Month Day Year. <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. vn�-k\ I2. 4. <br /> 3. <br /> 20.Designated Facil er or rator:Certification of receipt gipazardSpsAeriais covered by the manifest except as noted in Item 118/ 11117 <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) revious editions are obsol te. DESIGNATED FA ILITY TO DESTI ATION STATE(IF REQ RED) <br /> 10934.1444 <br />