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Please print or type. Form designed for use on elite (12-pitch) typewriter.) <br /> <br />Form Approved. OMB No. 2050-0039 GENERATOR I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAL000398/13 <br />2 Pogo 1 of <br />,. <br />3. Emergency Response Phone <br />MOO) 424-9300 <br />4. Manifest Tracking Number <br />013083312 JJK <br />Generator's Name and Malting Address Generator's Site Address (if different than mailing address) <br />tiiti ON t.1.4 .s-r()csToN <br />9603 iVINO6441, COVE RD PO IIDX 192 CA DIQ1-4 STOCKTON (::. HOLT <br />Generator's Phone: 91.& 289-7797 I <br />Transporter 1 Company Name U.S. EPA ID Numoer <br />ASEIURY ENVIRONMENTAL, SERVICES I CAE/02E271 3 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />FaciliVs <br />Designated Facility Nemo and Site Address 4 U.S. EPA ID Number <br />MEM 0 / RENNOOt. <br />.v00 NORTH ALAMEDA STREE I <br />COMPTON CA K422 °!. <br />(31.0 .)6.17-71.(X) 1 C A. T080013352 <br />Phone: <br />ga. 9b. U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />KM and Packing Group (if any)) No Type Quantity WI.Nol. <br />1' NON -RCRA HAZARDOUS WASTE. I IQUID ITALY WATER) <br />. <br />0 0 1 T T , 223 <br />6 op <br />2 <br />...... <br />. .,, <br />4 <br />14. Special Handling Instructions and Additional Information <br />NAERS4 9131. . 171. * PROFILE • tial : ACP *EMERGENCY CONTACT: ONEWITHEO 1,400-4244300 <br />AUTOMOTIVE CAARIPIER PROORAM *** * ADDMONAL EPA CODES ; 901; , NONE 4 APPROPRIATE PERS,ONAL <br />PROTECTIVE EOUIPMENr <br />15 GENERATOR'S/OFFERORS CERTIFICATION: thereby declare Mal the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and tam the Primary <br />Exporter, I certify that the contents of this consignment conform lathe terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 292.27(a) (if tam a large quantity generator) or (b) (VI am a small quantity generator) is true. . <br />Generator'slOfferor's Printed/Typed Name Signature . , Month Day Year <br />I I tri I til I I 41 <br />—1 <br />1— <br />3 <br />16. International Shipments • <br />Import to U.S. Export from U.S. Port of entry/exit <br />Transporter signature (for exports only): Date leaving U.S. !TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature' , Month Day Year <br />"I <br />n I <br />1 , <br />, + : I Ill I ki 1 I 14 <br />Transporter 2 Printed/Typed Nurse Signature '''' -N"--, Month Day Year ... <br />I I I 1 -4-- DESIGNATED FACILITY 18. Discrepancy .. <br />Discrepancy Indication Space li Quantity Type Residue ElPartial Rejection ElFull Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />1. 2. 3. 4 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as sided in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />I I I I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />