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- - - <br /> a, t <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) - Form Approved.OMB No.2050.0039 j <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number { <br /> WASTE MANIFEST C A L.0 0 0 3 710 396 ( i� 017791207 JJ K <br /> 5.Gen f tor' d Mail',n /fid cess Generators Site Address(if different than mailing address) <br /> IfN pi��& <br /> 040 R0EN {SAL AVE <br /> uta 95376 I <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.SEPA ID Number <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 /> (f k'VdOL9JGY VERNON INC <br /> 5376 SOM14 BOYL AVENUE <br /> Facility's Phone; <br /> 9a• ' 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit ! <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Nol. <br /> MM001,13 WMv TE lJJ_(Oil,:AND AWSOR EN o <br /> 014 V <br /> Z 2: <br /> w <br /> 3 . <br /> 4: <br /> 14.Special Handling Instructions and Additional•Information P, <br /> ( a" <br /> S'3 ' f 4Vt; 00H)ACT"�' :t ii 'R E bw$t - �t3t� t? IM(AI6`AL:4)IFRE'0 �`36><�:RGO 961 :�,1 "PROFILC 41981 <br /> AP204487OIL AND ABSORBENT 80 r 0 49 *APPRO RIATE'' EtSONALRC;}TEt,`NIV EQUIPWIt.r <br /> `f <br /> 15. GENERATOR'S/OFFl$ROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and,ac6urafe7y�escribed aboveyythe propershipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable int 'atipfial and nptional Bove riiental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm nt of Cbrtsent�r <br /> I certify that the aste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generato)or(b) if I a�t�a+mall q ntity generator)is true. <br /> G`e�nerators/Offer rs. nt q/T pe Name t }� f� �gnatures,; j Month Day Yea f <br /> t <br /> 16.InternationalShipments it f! <br /> r- ❑Import to U.S. ❑Export from U.S. Port of entryle w <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> ,r <br /> W 17.Transporterftnov ledgmept of Receipt of Materials !: <br /> Transporter Printed/Typed lame i Signature �; Month Day Year <br /> () 4 I <br /> a. <br /> QTransporter 2 PrintedlTyped Name Signature Month Day Year- <br /> 18, <br /> ear <br /> 18.Discrepancy. <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue j ❑Full <br /> El Rejection Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year. <br /> Q <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 <br /> 1. 2.C3 <br /> 3• 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name C Signature Month Day Year <br /> :{ ���.�.�"..: � �r(>,,.iR � 1•%� �:�o+s � �' t�' l„��-t�f` ���i i�;�`:. I <br /> EPA Form 8700722(Rev.3-05) Previous editions are obsolete. f:' TRANSPORTER'S COPY <br />