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Please pent or type.(Form designed for use on elite{12-pitch}typewriter.) Form f4npmved.OMB No.2050x39 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.klanifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 3 0 4 2 3 1 (804)424-9300 182 3 7 7 3 JJ K <br /> 5.Generators Name and Mailirig Address Generators Site Address['rf d f�erant than mailing address] <br /> Q AND M, DBA TRACY CHEVROLET-QAN001 <br /> 3400 AUTO PLAZA WAY' <br /> TRACY CA 95304 <br /> Generators Phone, 209 835-4500 <br /> 6.Transpo ter 1 Company Name U.S.EPA Ip Number <br /> WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.TrarrWef 2 Company Name LIZ,EPA ID Number <br /> 8.uesignated FaciNty Name and Silo Address <br /> U.S.EPA tp Number <br /> LIS ECOLOGY VERNON INC <br /> 6375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 <br /> Facie sPhone: -1 finn CAD097030993 <br /> ga. 9b.U.S.DOT Desalphon(nctuding Proper Shipp rig Name,Hazard Class,10 Number. 111.Containers <br /> HM and Packing Group tri any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type quantity WLN01. <br /> 0 1'NON-RCRA HAZARDOUS WASTE,SOLID(BRAKE LATHE SHAVINGS) <br /> 181 <br /> i 2. P <br /> :y <br /> c� <br /> 3. <br /> 4. <br /> 14.Special hlandWng Ir>stu[tioris andAdditianal InfomraHon �� <br /> EMERGENCY CONTACT:CHEMTIREC 1-SW424-9300 WOES TERMINAL.CERES NAERG#9131:171*PROFILE#gel: <br /> 601.528 BRAKE LATHE SHAVINGS*P500.00079469*APPROPRIATE PPE EQUIPMENT `MOF I,�r F <br /> 15. GENERATOR'SfORFEROKS CERTIFICATION: I hereby declare that the mntenls of this mnstgnmem ed ab are fully and accurately described r shipping name,ab are das`tiied..paciaq d, <br /> marked and labeledlplacarded,and are in an respoctg is proper condition for transpod according to appticade nlemabm oral govemmantal regrla' K eport s <br /> Ezponer,1 cm8fy that She oontert of this oDnkinmeot conform to the tarns of the auachad EPA t and i am the Primary <br /> I certify that dee m'Nmizatiar statemam identified in 40 CFR 262.27(a) if I am a la a uanti ,sent. <br /> [1{ n9 q or @](dl am a small quantity gereratcr' e. <br /> s Slgnftm Month pay Year <br /> 16.Into cl Shipments <br /> ? ❑Import m U.S. Purt of enhky e <br /> Transporter signature(for exports oniy): Date teat ng U.S.: <br /> 17.Tran5pbrterAdm oviedgmerd of Receipt of k awtals <br /> � Tea r 1 PrintedfT <br /> Oa SigMonth Day Year <br /> Q Transporter2PrintedffypedName Signature L67 <br /> a Month Day Year <br /> W <br /> 18.Dsmepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue <br /> ❑Portal RajeG7ipr ❑Full Rejec9on <br /> ManFesl Reference Number. <br /> 186.Alternate Facility[or Generator] <br /> J U.S.EPA ID Number <br /> U <br /> Facility's Aherne" . <br /> uj fOC.'VMtUreofAnemakeFadlity for C-anerator) <br /> a Month Day Year <br /> x <br /> w19-H Waste Report Management Method Codes(i.e.,mdes for hazardous waste treatment disposal,and rft ng systems) <br /> G t• <br /> 4. <br /> 20i.Designated Facility Owner or Opera4oCeffbmton of receipt of hazardous materials covered by the mantlest except as noted in Item 18a <br /> Pdn Hama Signature Morrih pay Year <br /> EPA Fart,8700-22(Rev.3-057 Previous editions are obsolete. DESIGNATED FA LITY TO DESTINATION STATE(IF REQUIRED) <br />