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C A L.�C�7()I .ta`-I <br /> Pease print or type.(Form designed for use on a de i2-pitch pewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Fhene 7011821828 <br /> .hianifest Tracking Number <br /> WASTE MANIFEST y—E ,� t- E} 1 (1-3,0�) '1`2-4-9300 JJ K <br /> 5.Gereratofs Name and Mad!nq Address Generators Site Address(if different than mailing address <br /> 344-7 NIARCONI-AVE �i t e%eI av\ <br /> AcPAMENTO �,DS , 240 <br /> -- <br /> Genemlofs phone: 5iG 443-2,i -s, <br /> 6.Transporter 1 Company Name k 4. U.S.EPA ID Number <br /> ASSURY EMM10VIENTAL SERYX'ES C A D 0 9 2 7 7 it 3 8 <br /> I.Transporter 2 Company Name 0 C T 2 3 2014 U.S.EPA ID Number <br /> 8.Cesgnaled Fao:ty Name and Site Address U.S.EPAID Number <br /> D)( DF ON ENVIRONMENTAL. HEALTH <br /> 7300 CHEVRON WAY DERA RY1ViPNT <br /> DIXON CA 956210 <br /> Facilityes Phone: r707)693-P,008r:A T 0 Et t? > ='s; t) <br /> 9a 9b.U.S.DOT Description(including Proper Wpping Name,Hazard C!ass,ID Number, 10,Containers 11.Total 12.Unit 13.Vtaste Codes <br /> Hhl and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) 00± ►T 6 223 <br /> Z 2. <br /> U, <br /> 3. <br /> 4. <br /> 1 <br /> i <br /> ! <br /> 14.Spec:al Handling Instructions and Adddicnal InfcrmaCcn <br /> NAE G#t 92-t: 171 "1 PROPILE#9Si:DKIOM7 EMERGENCY CONI TACT:C:HEMM 7-C:8 0t'M24-9300 to <br /> ADDIT1014AL EPA CODES:9131: ,NONE *APPROPRIATE PERSONAL PROTECTIVE EQU1PIME'I T <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this censgnmenl are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper ccndit'son for transport according to applicable tnte national and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certily that the contents of this consignment conform to the terms of he attached EPAAcknowledgment of Consent. <br /> I certily that he waste min:6zation statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or( (if I am a smakuantity generator)is true. <br /> Genwloesl0fferoes Printed/Typed Name S!gnature Month Day Year <br /> J 16.intemational Shipments <br /> t 11Import to U.S. ❑Export from U.S. Port of entryle 4 <br /> ? Transporter s".gnature(for exports only): Date leaving U.S.: _ <br /> w 17.Transporter Acknowledgment of Rece'pI of hlatedats <br /> Transporter 1 PrinledlTyped Name Vonature Month Day Year <br /> Q Transporter 2 Printedfryped Name Signature Month Day Year <br /> K <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ', QuanRy ❑Type ❑Residue ❑F a Gal RciecCcn ❑F'I Re;scticn <br /> Manifest Reference Number. <br /> 18b.Alternate Focally(or Generator) <br /> U.S.EPA ID Number <br /> J <br /> U <br /> Q Facititys Phone: <br /> LLJ <br /> 18c.Sgnature of Alternate Fac lily(cr Genera!or) <br /> !cnth Oay Year <br /> S • <br /> z <br /> 19.Hazardous Waste Report Management Mehed Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> uz Fo 9 (• P ! 9 Ys ) <br /> LU 1• 2. 3. 4. <br /> 20.Designated F.,Atj 0.vner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded n Item 18a <br /> Pdnledffyped Name SignatureMonth Day Year <br /> EPA Form 8700-22(Rev.3 05) Previous editions are obsol©le. I I <br /> DESIGNATED ;=aC1!l!l'id DEST)1i 1:ll lOi<1 STS?E{l n��..QU)RrD) <br />