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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved,OA).8 No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I CAL000368973 1 (300)424-9300 010853096 JJK <br /> I 5.Gencralor's Name and Mai`ng Address Generalor's Site Address(if different than maigng address) <br /> TRACYSHELL <br /> 1.040 N.BENSON All 3725 N.TRACY IiLil>a <br /> UPLAND ,� ^�_ CA RAD 5�t7ti6 t'R!8 TRACY CA 915804 <br /> ' 09 635 760th <br /> Generator's Phone: �. <br /> 6.Transporter I Company Name <br /> U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES C A D 0 2 8 2 7 7 0 C <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ' SIEMENS INDUSTRY,INC. j <br /> 5375 SOUTH BOYLE AVENUE <br /> -LOS ANGELES CA 900bg C A 0 0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: (3231277.15 00 <br /> ga 9b.U.S.DOT Descriplioo(including Propor SNPpktg Name,Hazard Class,10 Number, 10.Containers It.Total 12.Unit 13.Waste Codes <br /> I and Group if an Quantil WWoL <br /> Hid 9 P(• Y)) No. Typo Y <br /> 1,ICON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) 352 <br /> Z DN1 <br /> W 2. { <br /> ' W F <br /> 3. <br /> r <br /> 4. <br /> 14.SpecialHandling Instructions and Additional Information - <br /> EM.ERGENCY CON TACT:CHEIVITREC 1-800424-9300 NAERG#9BA:171 PP9FILE#JPS : '.�t��S�i.r24 OILY <br /> SOLIDS*POP A110162743"APPROPRIATE PERSONAL PROTECY7VE EQUIPMENT (- t 5 bit( E "� o <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this ccoslgnment are fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and labeledrpiacatdod,and are in all respects In proper condition for transport according to applicable internationaiand national governmental regula'O`ons.If export sh'pmenl and I am the Primary <br /> Exporter,I'certify that the content's of Ihts consignmont conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste p1AmizaW, statement idenI fed In 4D CFR 262.27(a)(if I am a largo quanFly gonerator)or(b)(if I atm a smallclaanRy generator)is true. <br /> GeneraloeWfferoes PrintediTyped Name I kJi f Month Day Year <br /> 16.International Shlpmenis <br /> ❑Import to U.S. ❑Export from U.S. Port o(entryfoxif: <br /> z Transporter sig lure(for exports only): Dale leaving U.S.: <br /> W 17.TranspoderA owle4mentofRecelptofMaleda;s <br /> Transporter i Printed/Typed IN a Sgnatute Meath Day Year <br /> o C((16 f00 1 <br /> udi <br /> Signature Month Day Year <br /> z Transporter 2 Prig ed/TypedNamo � <br /> 18.Discrepancy <br /> 18a,DiscrepancyInd'cation Space. El Quantity ❑Type ❑Residue ElPartial Re)edion ❑Full Re!ed'on <br /> Manifest Reference Number: <br /> 18b.AtlernateFaddity(or Generator) ? U.S.EPA IO Number <br /> U <br /> u- Facr':itysPhone:, MonthDay Year <br /> w 18C.S?gnalureof{'JlernateFac3ity(orGeneralor) <br /> a <br /> z <br /> 19.Hazardous Wasie Report Management Method Codes(,e„codes for hazardous waste treatment,crisposal,and recycling systems) <br /> W[� 1 2. 3. 4, <br /> 20,Desgnaled Pacitify Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in flem 1 Be <br /> 11'rinled/Typed Name Signature Month Day Year <br /> I <br /> EPA Forth 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATF_(IF REQUIRED) <br />