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�p ti-4-d, r 1C4-_,41)f C_ 1,� <br /> Ffeaso prat or type,(Form designed for use on elite(12-pitch)typoviriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS- 1.Generator ID Number2j Pago i of 3.Emergency Response Phone 4,Manifest Trackin !lumber <br /> WASTE MANIFEST C A I, 0 0 0 1 8 2 6 Q 5 (Sdf?� t2,6-93000 0 9 5 7 3 2 0 A <br /> 5.Gane0tl ff�*2 dress Gersaralof's Sllanddross Of O.arent than mailing address) <br /> E.KF-MFWN RD. <br /> LOD) CA 95240 <br /> GCnt3rfll0�S Phofte: 2W 30 <br /> e.Transporter t Company Name U.S.EPA ID Number <br /> ASBURY EWIRONNENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br /> T.iransportet2 Company Name U.S.EPA ID Number <br /> S.Desigpaled,E�,rt'itvt't;3ma and Site Address U.S.EPA ID Number <br /> UUDff)SS UU0 CCLL7CHEVRON WAY OA g6620 <br /> CT071�3 E48 C A T 0 8 0 0 1 2 6 0 2 <br /> Fact'[[[[[ s Phone: <br /> 9a, 5b,U.&DOT Description Qncfudirtg Peoper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pacldrg Group(if any)} No. Type Chan y VJINd. 13.N'asla Codes <br /> i. y o f 223 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER) <br /> 00 1LU <br /> 2 <br /> 3. <br /> OCT 0 6 2014 <br /> t <br /> 4. <br /> ENVIRONMENTAL HEALTH <br /> PARTMENT <br /> 14.Speaai fiand'n iastnrdbu and Additional to ornaLLon <br /> NAERC 9B1 : 171 'PROF) E#981 : DK110442`EPvERGENCY CONTACT: CNEMfREC t-Odd-424-9300'ADDITIONAL. EPA <br /> CODES:991 : , NONE"APPROPRIATE PERSONAL PROTECTIVE EQUIP.NENT <br /> 15. GENERATOR'S/OFFEROWS CERTIFICATION:I hereby cedars that the contents of this consignment aro Maty and accumlely described above by the proper shippirtg name,and are classified,packaged, <br /> marked and labeledlpiacarded,and are In at respects in propef w iditon for Iramporl accorcing to applicable Inlemationaiarid national governmental regulations.If expert shipment and I am the Pant jy <br /> Exporter,I certfy that the contents of th[s consignment conform to the terms of the attached EPAAc'znowledgment of Conseol. <br /> I c*rtify that the waste milatmizatfon statement Identified in 40 CFR 262.27(x)(f t am a large,quantify generator)or(b)(if I am a sma}(quanGlygenerator)is true. <br /> Genora =ffdroes Printed/Typed Name, Signa are month Day Year <br /> —a iS.intoonauartaiShipments <br /> {- ❑import to U.S. ❑Export from U.a. Port of enlryfeAU <br /> Transporter sigratule(for exports only)! Data fea*g U.S.: <br /> U tl,TransporterRGsnan4edgmentofReceiplofMatedals <br /> 0, Transporter t YrintedtTypad Name Signature Month Day Year <br /> b <br /> $t5ortdr 2 Prntted/Typed Nang Signature Month Day Year <br /> Ia.Discrepancy ((��tt rf�� <br /> l8a.Discrepancy Indication J Spaca LCuan y ❑Type El R"ldvo 0 Patial Rejecjon ❑Futi Rejection <br /> 4lanllesi Reference°dum,5er. <br /> 18b.Atternala Faa!ify(or Generator) U.S.EPA;)Number <br /> C7 <br /> U- Facility's Phone: <br /> W ?ac,5tynatum oiNternaie Pacrtity(or Generator) hicoul tray Yecr <br /> d <br /> r <br /> � 19.Hazarktaus'Nasto Report fsianagement Methcd Codes(i.e.,modes for hazardous ivas(o Uasunent,disposal—,am raCy,#ing sys(ems) <br /> U 1. 2 3. 4. <br /> 20.Doalgnated Faclty Owner or Operator.Confocal on of rec elpi of hazardous materials covarod by;he manitast oxcepl ns ndad In Item l8i <br /> FhfflcdJf ed Name 59ra1' 1,kxdhDa' Year <br /> t r e+'1d o_e� �. Joe e,5/ /Z <br /> g Form 0700-22(Ray,3 05} I'mmus nditlons areobtiolete, DESIGNATED FACILITY 1'0 DESTINATION STATE(117 nEQUIRED) <br />