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Please print or type.(Form designed for use on elite(12•plidi)iypoviriter.) Form Approved.Oh18 No.20500039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L O O O i 8 2 6 4 6 1 (800)424-9200 01 110 JJ <br /> K- <br /> 6. <br /> 6.Gener�rJ taaedfilflys Generators Site Address(it d+lterentThanmatingaddress) <br /> 600 E.KETTLEMAN RD. CA 96240 <br /> Generatofs Phone:LO 209 339-0900 <br /> d.Transporter 1 Company Name U.S.EPA IDNumber <br /> ASBURY ENVIRONMENTAL SERVICES ,, ; ,: CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transputer 2 Company Name U.S.EPA ID Number <br /> 8.Des'gna��f 0 and Site Address U.S.EPA ID Number <br /> {7J31(30 BUJ EVRON WAY ENVIRONMENTAL HEALTH <br /> MXON CA 95620 <br /> GAT480012642 <br /> Fac,' sPhone: (70T)693-8008 cam= -. ,1—.1,T <br /> 9a. 9b.U.S.DOT DescripCon(inducing Proper Sh'pptng Name,Hazard Class.ID Number, 10.Conla'ners 11.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. T)•pe Quantity tvtrvol. <br /> NON-RCRA HAZARDOUS cY i WASTE, <br /> LIQUID(OILY WATER) G 224O <br /> i <br /> 2. <br /> U <br /> 3. <br /> I <br /> a. <br /> 14.Special lfan0ng Instructions and Add Conal Infonnaron <br /> NAERG# 9B1:171 • PROFILE #981:DH110442 *EMERGENCY CONTACT:CHEMTREC lr800.4249300 t <br /> ADDITIONAL EPA CODES:991 : .NONE *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GEtiERATOR'S10FFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are My and ac"rale:ydescribed above by the proper shlpp'sng name,and are classified,packaged, <br /> marked and labetedlptacarded,and are In a1 respects in proper Gond Ven for transport according to aWzcab!e Olern.0onai and nal'onal gm emmentai fegulaions.if export sh!pment and I am the Pr'dmary <br /> Exporter,I certify!hal the contents of thls cons!9nment con!oim to the terms of the attached EPA Acknan' menl of Consent. <br /> I certify that the waste m!n'niaaton statement identAed In 40 CFR 262.27(a)(ill am a large quantity sero or)or(b)(ill am a smart quant goneralor s We. <br /> GeneratofsVI'erofs PrintedrTyped NameS,tori ro / Month Day Year <br /> r <br /> 10 7 U31 <br /> 16.intematiwal Shipments <br /> ❑Import to U.S. Export front U.S. Pod of entrylexic <br /> Transporter sgnalure(for exports only): Date leaving U.S.: <br /> 17.TiansporterAcknaa:edgmenlof Rece�tof Materials <br /> Transporter 1 Prinledrryped Name Sgnature 6:onth Day Year <br /> a. Liko Pe-s-&,v D 7 -Z <br /> Z Transporter 2 Pr'ntedfryped Name S-Snature Month Day Year <br /> 18.Dscrepancy <br /> ISa.Discrepancy Ind:caron Space El Quantity ❑Typa ❑ r Resktue ❑Partial Re`ect ori Fu 1 Re'ect:on <br /> 61an:fesl Reletente Number. <br /> 18b.Ailernale Fac1ty,(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rQ Fa6l:ysPhone: <br /> W 18e,SlgnatureofAllemateFa0q(of Generalor) 11ortm Day Year <br /> a <br /> Z <br /> 65 10.Hazardous Waste Report f ranagemer% odrod Codes(i.e..codes for hazardous waste lrearmont,disposal,and(ecWmg systems) <br /> W 1 77- <br /> 2. d. <br /> Ca 4N/ I _ <br /> 20.Doslgnat Fa&ty 0.%noW Cpeialor:CeitiLrauonofrece!piofha smaterialscoveredbythemardestexceptas In item18a <br /> Prinled(T ed Name , ,/ S'.9 nature p, �� b' Day Y <br /> YP <br /> Y / <br /> EPA Fon 810022(Reu3 5) Previousedilionsar obsolete. DESIGNATED FACILITY TO DES'T'INATION STATE (IF REQUIRED) <br />