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Iq <br /> Please print or <br /> type.(Form des' ned for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator 1D Number 2 Page 1 of 3.Emergency Response Phone Z.Manifest Tme"Nambar <br /> WASTE MANIFEST G A L 0 0 0 1 8 2 i 4 Er 1 o0C}j d 44)300 009560128 JJK <br /> L Generalon's Site Address(ff ddferont than maBirrg address) <br /> -- <br /> RM E KETTLEWN RD. <br /> 1_001 . CA 95-240 <br /> GeneratcesPhone: 209 339-M <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY EW1 RONNENTAL SERVICES _ C A D 0 2 6 2 7 7 0 3 5 <br /> 7.Transporter 2 Company Name UU1 2 3014 t U.S.EPA ID Number <br /> 6.°a,+ssiE► i ��vnU�dSles �°rd�ic. ENVIRONMENTAL HEALTH US.EPA ID Number <br /> ANGE':075 SOUTHLES BaYLE AVENUE <br /> LOS AI`1t DEPARTMENT C A D 0 X 7 0 3 9 9 9 <br /> LacLES CR see <br /> Facifity's Phone: r�i 22T1 <br /> ga. 9b.U.S.DOT Description(ndudag Proper Shipphtg Name,Hazard Class,ID Number, %conlaitters 11.Total 12 Unit <br /> 9 Gro <br /> and Paddn an 13.Waste Codes <br /> M4 and ( Y)) No. Type Quantity WtNot. <br /> 1. r <br /> P_ NON-RCRAHAZkRQOUS WASTE,SOU0 (OiLYSOLIDS) � <br /> 7- <br /> 3.3. r <br /> i <br /> 4. <br /> 14.Spedal Handfing Instructions and Additional Information <br /> EMERGENCY CONTACT: CHEMTREC 1-M-42+ NAERG#981 : 171 =PROFILE#881 :API OILY SOLMIZ'PC# <br /> Al 101 49GMrAPPROPRIATE PERSONAL PROTECTIVE EQ!IPNENT <br /> 15. GENERAMR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignunentare fully and accurately described above by the proper stdppfng name,and are dassHted,padcaged, <br /> madaed and labeledlplacmded,and aro In all respects In proper condition for transport according to appfcable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAd=Aedgment of Consent. <br /> I certify that the vraste rNrimnaation statement identified to 46 CFR 262.27(a)(d I am a large quantity generator)or(b)(di am a small quantity ganerator)is true. <br /> n °��Prin ' I ,� <br /> 3 <br /> J 16.International Shipments <br /> Import 113U.S. ❑Export from U.S. Pori of en tryfexit: <br /> Transporter signaWre(for e>ports only): Data leaving U.S.: <br /> 17.TransporterAdmowledgment of Receipt of Mads <br /> Transp r 1� Name � r„ SriMonth <br /> oQ. e. <br /> 7914 <br /> Trarfsporter2Prin Name gnature Month Day Year <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑PerW R.I.-:6oa ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b:Aaemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ra Facility's Phone: <br /> 18c.Signature of Alternate Faallty(or Generator) Month Day Year <br /> a <br /> a <br /> 19.HazardMWasLqRepo#Management Melhod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU G 1. 2. r <br /> 4. <br /> Ll20_Designated Adiffty bAe,or orator.Cerh3caiion of recelpt of hazardous tedals covered by the manifest except as nded in 109 18a 174 <br /> Print&dffyped Nam I// Slgnamre Month Day Year <br /> I 4�� hc 0 1 <br /> EPA Fonn 8700-22(Rev.3-05) Pr viouseditlonsare <br /> obsolete. DESIGNATIF-b4ACIll iI Y 0 6ESTINATION STATE(IF REQUIRED) <br />