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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I CAL 0 0 0 1 8 2 6 4 6 1 (800)424-! 014058490 JJ K <br /> 5.Generato <br /> s N m4 Md ilin 7ress Generator's Site Address(rf different than maNirg address) <br /> YBlE#2 <br /> 730 S. BECKMAN ROAD <br /> LODI CA 95240 4715 N.WEST LANE MONTHLY BILLING <br /> Gerreretor•s Phone: <br /> 209952-1662 STOCKTON CA 95210 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: (323)277-1500 <br /> 98. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 1. NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS-PAPER FILTERS) 352 <br /> 0 <br /> DIV 4x'0 P <br /> z 2. <br /> w <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 NAERG#961: 171 *PROFILE#9131:AP192210 OILY SOLIDS- ER <br /> FILTERS *P500-00022093 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMEN <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects In proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the teens of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOfferoes PrirdedlTyped Name Signature Month Day Year <br /> _j 116.Intem tonal Shipments <br /> ❑Import to U S. Export flmport to U S. Export from U.S. Pad of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> Of 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans 1 PrintedfTyped Name — Signature Month Day Year <br /> 0 <br /> CL <br /> QTransporter 2 Printecirlyped Name re Month' Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Refection ❑Full ReJection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> pMonth Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> V519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 � � 2, 3. 4. <br /> 20.Designated Facility Owner or enamor.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> )&v <br /> EPA Form 8700-22(Rev. 5) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />