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Please print or e. Form designed for use on elb 12-pitch typewriter.) 1 'Form Approved.OMB No.2 0 0039 <br /> P type.( 9 ) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4,Uardfest TraNumber <br /> WASTE MANIFEST (r ;i c�c� �����4 � t��Gi 4d�=qac-01010§�5959 JJ K <br /> 5'.Generator's Name and Ming Address Generatoes,b Address(it dMarent than melBrg address) <br /> 5001 E. ti E� T�iu. <br /> :r•ntin <br /> "x` <br /> re <br /> 'u0 <br /> Generatoes Phone: V 1 2219 J�0,0 <br /> rter <br /> 6.Transpo1 Company Name U.S.EPA 10 Number <br /> ASBURY SERV,— a H4 <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> B.Dest nated FaoiEty Name and Site Address ENVIRUNMENIALH ALI h U.S.EPA ID Number <br /> S"EMENS INDUSTRY. DEPARTMENT <br /> FadrrtysPhone: -323-1277--500 <br /> 93. 9b.U.S.DOT Desmoon(ndudng Proper Stopping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13.waste Codes <br /> HM and Parking Gnngr(d any)) No. Type �Ouamlfty WtNaL <br /> 1. <br /> "lrY352 <br /> � l <br /> � t <br /> O <br /> 2 . <br /> W <br /> C7 <br /> 3. f <br /> f <br /> 4. I ) <br /> n <br /> j <br /> 14.Spedal Handfi ng Irrtvbrrctions and Addhlonaf Information <br /> RAEn S �' i_O: Y <br /> r `4t'• <br /> n <br /> A}P+3r i 71tPE' -v +1 PR` h;;11 '7� 7/L <br /> t <br /> 15. GENERATOWS)OFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment'era fully and 2=ralely deemed above by 9ta mper shlppmg name,and are tdassdied,packaged, <br /> marked and labeledlplacarded,and are in al respscts m proper condition for transport according W appkable intematmnal and national govwwnsnlal regulations.If export shipment and 1 am the Primary <br /> EVnfier,I ce fty that the Corrtt'ittS of tNS Mr*jgnmenl wnform to the terns of the allached EPAAdmowtedgment of Consent. <br /> I certify that are waste minimization st demerd identified in 40 CPR 262.27(a)(if I am a large quantity generator)or(b){dt am a sinal ardity generator}is true. _ <br /> Generator`slOfreroes PrintedNyped Name Ngflaut <br /> t 16.International Shipments <br /> Import to U'S. ❑Export from U.S. Port <br /> Z Transputer signatura(for exports only): Data <br /> w 17.hansPorierAdanowled9mertt of Receipt of 1+Aaterials <br /> Transporter 1 Pdrrtgilfr!yped Name <br /> CL �7b11•, �f/� Mwth Day Year <br /> Toa r 2 Pr tedrtyped Name <br /> K <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity []Type ❑Residue ❑Partial Rejection El Fuff Rejection <br /> Manifest Rorietance Number. <br /> U.S.EPA ID Nulrsber <br /> lab,Abmate Facft(or Generator <br /> J <br /> U <br /> obi- FdWs Phone: Month Day Year <br /> 18c Signature ofA2emo Facility(or Generator) <br /> Lua <br /> (2 19.Hazardous Wa R rt Management Method Codas M.,Codes for t�rardous areata beatnrenL dispo�l,arta recydng systems) <br /> Q 1_ 2 3. 4. <br /> n�L I .... <br /> 20,Qle�gWXW Facliiy Oww or Operate Of mcelpt 0f rozardws materiets by the manifest except as ndBd In Item 18a <br /> srgnattre 6Mon1h Day -Year <br /> P ante <br /> FPA Form 8700-22(Rev.3-05) Previou9echom are obsolete. DESIGPJATE© FACILITY TO DESTINAT1oN STATE(IF REQUIRED) <br />