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Please nt ort (Form designed` for use on elite 12 itch her. AM roved.OMB No. 5 9 <br /> Pn type.(� ( -P )h'Pe� ) APP 20 0-003 <br /> UNIFORMHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 015�6 4� � f80,0--��;-9s�Q 010863149 JJ K <br /> S.Generator s Name and Mailing Address Generator's Sole Address(d dttTerent than malting address) <br /> IIIFFY LUBE#2213?s <br /> 500 E.KETILEEtAN RE). C.4 r-*-- <br /> Genemto aPhone: 209�vM900 55 24 ..� , <br /> 6.Transporter 1 Company Name U.S.EPA ID Mmrber <br /> ASRURY C A LI 0 S Z,7 7 0' <br /> 7.Transporter 2 Company Name ( U.S.SIA 10 Number <br /> 8_Designated Facility Name and Sts Address E NVI R O N M E NTA L HEALTH U.S.EPA ID Number <br /> SIEMEN-S INDCS T R •iiiNC. <br /> 5375 SOU-17F BOYLE RVEME. DEPARTMENT <br /> LOS ANG ELE CA Fj005S CA0057033993 <br /> FacmvsPhone: f3"��.I277-1.500 <br /> 91 9b.U.S.DOT Description(mdudmg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 unit 13.Waste Codas <br /> ISS and Paddng Gmup(dany)) No. Type Quantity WWoI. <br /> 1. OrEt�:RA taiarJ+; ki 352� <br /> c � <br /> i l <br /> D4 <br /> LU <br /> w 2. <br /> c� <br /> 3. E <br /> r <br /> I i <br /> 4. ` <br /> ( <br /> 14.Special Handling Instructions and Additional Information r <br /> - <br /> #994M. APtVf 9 <br /> 8 MkEMERGEN-CY'CONTACT <br /> N ACT_CHE " E . 2wSh!UL42 9300 AERI#981 -7" . 1FIi. <br /> CIUDS <br /> s P0#A:Lft}1a3997 r APPROPRIATE_PfERSONAL PROTECTIVE EO`LiPMEN; <br /> 45 Z <br /> 15. GSNERATORISIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and aomuateby desated above by the proper shipp"name,and are classified,pil ged, <br /> marked and labeledtptacarded.and are in a0 respects in proper condtion for transport according to appRrable i bt rretiord and national gavelru RMS regulation s.If wqW shipment and I am the Pendry <br /> Exportur,l cerdfy That the contents of this consignment conform to the rams of rhe attached EPAAckrmhedg Twd of Consent <br /> I certify that the waste min mlrabon statement identified in 40 CFR 26227(8)(if <br /> lam a large quay City genera's or(b)(di am a s r&quantity generator)is true. <br /> Month gat- - <br /> Ift <br /> c ` , al'•\ 2` Oi Q 13 <br /> yyvI1 16.Inte a1 Shipments I to U.S. ❑Export from U. Pod of entrylerdt <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknmedgrnent of RecW of Materials Month Day Year <br /> O T der 1 printed/Typed Name Si / 113 <br /> / <br /> ... <br /> Trancpodw2PnntaWTypedName SignaAue Month Day Year <br /> H <br /> 18.DiSaepancy <br /> lea.Diss anoy Indreabon Space Quenfly Type ❑Residue ❑Partial Rejedion ❑Fud P4.bon <br /> Manifest Reference Number <br /> U.S.EPA ID Number <br /> 18b.Alternate Fac!iy(or Generator) <br /> J <br /> U <br /> Vac. Facility's Phone_ <br /> 18c.Signature of Ailernate Faciity(or Generator) MOTIth yew <br /> er <br /> z <br /> 19.Hazsrdow Waste,Report Mamagernert Method Codes(L._codes for hazardous waste treaUrtenk deposal.and recydng sysi-) <br /> O 1 i 12- 3. 4. <br /> 20.Desrgrtatod d*Ovmer oropo tor:C9r1jf11".aw reow of hawbMIS tnatenals CmEred by the n18r*9 except 88 In Item 168 <br /> � aIt16 � Month Icy Year <br /> EPA nrm 5700-22(Rev.3-05) Previous editions ata obsolete. DESIGNATED FACILITY TO DES-;KATION STATE(IF REQUIRED) <br />