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J v Facility's Phone: w 18c. Signature of Ahemate Facility (or Generator) Q 2 - y19. Hazardous Waste Report Management MethodCodes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) c Uj 1 3. / �/ 2. 20. esignated Facility Owner or Operator: Certifir4 ition of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledfTyped Name Signature _ EPA Form 8700 -22 -(Rev. 3-05) Previous editions are obsolete. 4. PA 101Voi DESIGNATED FACILITY TO GENERATOR Please print or type. (Form designed for use on elite (1. typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID umber 2. Page 1 of 3. Emergency Response Phone 4. Manifestacking Number WASTE MANIFEST C A D 8 2 0 3 0 1 (800) 424.9300 009 9ig95S J J K 5. Gene, (Qr'&g apcl Jyt irUg AD LIN 4 Generator's Site Address (if different than mailing address) 10031 FOOTHILLS 6L JOHN THOW 633 E 8TH ST aste. Our I . 10 Pq L'M Fe -ns GO 0J 2 602, RO&BlLLE GA. 9947 STOCKTON CA 85206 Generators Phone: 942^6224 6. Transporter 1 Company Name U.S. EPA ID Number iformation ASBURY ENVIRONIVENTAL SERVICES N+�tEER( 981: 171 *PROFILE C A D 02 0 2 7 7 0 3 6 7. Transporter 2 Company Name PROTECTIVE EQLIIP%eff U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number 15. GENERATOR'SIOFFEROR'S CERTIFICA N: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, DK DIXON marked and labeled/placarded, and are In all respects In proper condition for transport according to applicable Intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this co6signment conform to the terms of the attached EPA Acknowledgment of Consent 7300 CHEVRON WAY I certify that the waste minimization statement Identified In 40 CFR 26227(a) (If I am a large quantity generator) or (b) (If I em a small quantity generator) is true. DIXON GA 9W20 f D4 C F 1 Facility's Phone: 17071693-a" 16. International Shipments port to U.S. ❑ Export from U.S. Port of entry/exit I ct►TU90oZ25t�2 — Transporter signature (for exports only): Date leaving U.S.: 9a. 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 17, Transporter Acknowledgment of Receipt of Materials 10. Containers 11. Total 12. Unit O a HM and Packing Group (if any))13. Quantity WLNd. Waste Codes No. Type L 18. Discrepancy — 1 Be. Discrepancy Indication Space — - Ou 221 IvGWRCRA HAZARDOUS WASTE, LIQUID (USED OIUM7ED OIL) � 001 TT G 2c 2. W t� J v Facility's Phone: w 18c. Signature of Ahemate Facility (or Generator) Q 2 - y19. Hazardous Waste Report Management MethodCodes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) c Uj 1 3. / �/ 2. 20. esignated Facility Owner or Operator: Certifir4 ition of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledfTyped Name Signature _ EPA Form 8700 -22 -(Rev. 3-05) Previous editions are obsolete. 4. PA 101Voi DESIGNATED FACILITY TO GENERATOR rete v.a. , er waste, and has receik, the aste. Our I . 10 Pq L'M Fe -ns GO 0J 2 602, w X14` Spedel Handling Instructions and Additional h iformation N+�tEER( 981: 171 *PROFILE # 9B 1 : OK090072 ADS # OSP)" 2R-OW-GFM* ADDITIONAL EISA CODES: 981: , NdNE APPROPRIATE PERSONAL PROTECTIVE EQLIIP%eff 15. GENERATOR'SIOFFEROR'S CERTIFICA N: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are In all respects In proper condition for transport according to applicable Intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this co6signment conform to the terms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement Identified In 40 CFR 26227(a) (If I am a large quantity generator) or (b) (If I em a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year f D4 C F 1 16. International Shipments port to U.S. ❑ Export from U.S. Port of entry/exit I — Transporter signature (for exports only): Date leaving U.S.: 17, Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year O a ZQ Transporter 2 PrntedfTyped Name Signature Month Day Year 18. Discrepancy — 1 Be. Discrepancy Indication Space — - Ou my ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manfest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J v Facility's Phone: w 18c. Signature of Ahemate Facility (or Generator) Q 2 - y19. Hazardous Waste Report Management MethodCodes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) c Uj 1 3. / �/ 2. 20. esignated Facility Owner or Operator: Certifir4 ition of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledfTyped Name Signature _ EPA Form 8700 -22 -(Rev. 3-05) Previous editions are obsolete. 4. PA 101Voi DESIGNATED FACILITY TO GENERATOR