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use on elite 12- itch ewriter. Form Approved. OMB No 2050-0039 GENERATOR . ) UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number • <br />C A L 0 0 0 3 9.8 1 1 3 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />(800) 424-9300 ... <br />4. Manifest Tracking Number <br />014058.201 JJ K <br />5. Generators Name and Mailing Address Generatoes Site Address (if different than mating address) . <br />r.;,T ONE TTJS. - M1 J001 <br />8503 WINDMILL COVE RD . <br />STOCKTON CA 95206 <br />Generators Phone: .9113 289-7797 <br />B. Transporter 1 Company Name • U.S. EPA ID Number <br />ASBURY ENVIRONMENTAL SERVICES IC ADO 28 2 7 7 V -3 6 . . - <br />Transporter 2 Company Name U.S. EPA ID Number <br />t <br />Designated Facility Name and Site Address • U.S. EPA ID Number <br />DEMON° / KERDOON <br />2000 N. ALAMEDA STREET • <br />CaMPTON . CA 90222- ICAT080013 <br />Facility's Phone: . (310) 537-7100 <br />ga. 9b. U:S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers it Total 12. Unit 13. Waste Codes <br />MM and Packing Group (if any)) No. Type Quantity WLNol. <br />1. • . . <br />NON -RCRA HAZARDOUS WASTE, LIQUID (OILY SLUDGE) 223.- <br />••3 . 0 M jeCcG .. <br />2. ' <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information . <br />EMERGENCY CONTACT : CHEMTREC 1-800-424-9300 NAERG# 9B1 : 171 *,PROFILE # 9BI : , <br />032615-2 OILY SLUDGE I- POii A.110208095 'k . APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br />dX&7_5/' c2AtZ -S---6.r44.t <br />15 GENERATOR'S/OFFEROR'S CERTIFICATION; i hereby declare that the contents of this consignment are fully and accurately deserted above by the proper shipping name, an:I are classifiec, packaged, <br />marked and labeled/placarded, and are In at 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 contrm to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27 a)111 lam a large quantity goner b) (41 am a small qUantIty generator) is true. <br />''"-1-., Signature Cf7- Month Day Year Generators/Offerors Printed/Typed Name - <br />/ 1 1036/ ikl'' ..... <br />F- <br />E <br />international Shipments Import to U,s. Export from U.S. Port of entry/exit <br />Transporter signature (for exports only): - Date leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials <br />Trans ii Printed/Typed Name . ,• / i i Signature Month Day Year <br />I 4t7 1 :21 Ikr <br />ransporter 2 PrIn <br />f <br />yped Name Month Day Year <br />I III DESIGNATED FACILITY Discrepancy <br />Discrepancy Indication Space II Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone. I <br />18. Signature of Alternate Facility (or Generator) - Month Day Year <br />I I <br />IS. 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 noted in Item 18a <br />Printed/Typed Name . Signature Mont Day Year <br />I III <br />EPA Form 8700-22 (Rev 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED <br />