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Please print or type.(Form designed for use on elite(i2-pitch)typeWTri er) Fofm Approved.CNIB No.2050.0039 <br /> 1.Generator lD Numbu : Page t of 3.Emerge vy Respanso Phanu 4,hiaw((a�st Tr kfn�]Numbr �p <br /> UNIFORM HAZARDOUS 7 1 �800� �d-9300 U J 5 t 324 JJ K <br /> WASTE MANIFEST C A L 0 0 0 1 S 6 4 b <br /> 5.Gene l�n� n rws GanarMor'sSte Address(I diffeIart than malting address) <br /> WOE,KETTLEMAN RD, <br /> LODI CA 95240 <br /> L�9 a�a-os�o <br /> Generator's Phone; <br /> 8.Transporter f Company Name U.S.EPA ID Numhor <br /> ASBURY ENVIRONW-NTAL SERVICES C X> 0 0 2 8 2 7 ? 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Daslgpaled15Mme and Sita Address U.S.EPA ID Number <br /> 7300 CHEVRON WAY <br /> DIXON CA 3E6zU C A T 0 8 0 0 1 2 6 0 2 <br /> 17071593.6008 <br /> Facd s Phone: <br /> 9a 9b.U.S.DOT Des*6on{includ'+ng Proper SNpptno Name,Hazard Class.10 Number. EO.0tainers 11.Total 12.Unit 13.Waste Codes <br /> NM and Paedn9 Group(d any}) Tvpa Quantit 4VUVor, <br /> o NON-RCRA HAZARDOUS WASTE,LIQUID (OILY'WATER) 0 0 1 I T G <br /> 2, % <br /> n- <br /> 0ALU <br /> 3. <br /> OCT 0 6 2014 <br /> d. ENVIRONMENTAL HEALTH - �— <br /> D RENI <br /> fd.Sperlai Handtin fest ucl ars and Add(tfona!lnformaticn <br /> CrIAERO 961 : 171 `PROFILE#98i :DK1`10442`HVERGENCY CONTACT.'CHEMTREC 1 BOO-424-M m AI7C}IT70NA) EP <br /> CODES:9B1 ; ,NONE'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GEN ERATORVOFFEROR'S CERTIFICATiON:1 hereby declare that the contents of this consignment are fully and accurately described abova by fha proper slipping name,and are classified,packaged, <br /> marked end labelaplaeafded,and are to aff respects in proper concition for Uanaport accv(d4 to appllcahio internadonalend national go�reinmentat regulations.it export shipmant and I am the Primary <br /> Exporter,I cettity that the contents of this consignment conform to the terms of the attached EPAAcknow,iedgment of Consent. <br /> I"ttly that the waste mlydmlzatton statement Identified In 40 CFR 26227(a)(it i am a 12(98 quantity generator)or(b)(if I am a small quantit/ganaratat)is Uus, Menth Day Year <br /> Gemia efor'sPrintedlTypedName Slgnatx <br /> s7 <br /> NI1 dot c l 2 <br /> ib,int atkx at S ipme JI Fxpa from U.S. Pert of anbylexit: -- <br /> w ❑Import to U.S. Cato leaving U.S.; <br /> Transporter sgnatur6(far expcifs only): <br /> w 17.TranspoderAcSmr MaWats rzt Mon <br /> Signature <br /> d Ath ar <br /> Day Ye <br /> Trefoil ter 1 Pctnledriyped Name f, r� <br /> lo3n<, tilkCt1(Y A`{aJnth Day Year <br /> CTransportor 2 Printecirryped Name Sl9raturs <br /> r-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpmG <br /> ❑ ❑!T; e ❑ResIdus ❑Partial Re}eerian ❑Fuil Rafecan <br /> Quantii•J <br /> k{anIf851 RBf6rEilGa Nt1mU6(: <br /> U.S.EPA ID Number <br /> i 96.Alfoma(a Feai;ly{or Ganaratar) <br /> v <br /> w f`Gff1ty,5 Phoma: t;tonay Day Year <br /> 18c.Signature otNlemale Faa ly(or Gonarator) <br /> 19.Hazardous Waste Report N(ansgernent ldethod Codas(i.e.,cedes for halardouswaste freairnant,disposal,and rec,dIPg systems) <br /> u t 2 3, d. <br /> 20.Deslonateed Faciity Qvnar or 4paraior:CertifcaWA of recelpt of haaardous materials coveted t y the maraiast except as r d�n item SSa ranth Day Year <br /> ��9natera <br /> PrntedaypmName � /0 / <br /> '9 <br /> iRAFon9700-22(Rev.3.05) PftMUSeditiollSate0080I8te, fl-SIGNATED ACtLITYTC? DESTINATION STATE(IF REQUIRED) <br />