COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter) Forth Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I Generabr ID Number 2.Page t of 3.Emergency Response Phone 4.Manlfpt T Number WASTE MAyIFEST C A L 0 0 0 1 1 2 6 4 b + 424-9M Q O 3 5 9 7 4 JJ K 5.Generators Name and Meiling Address Generator's Sib Address(if 6%rertt than mailing address) JFFY LUBE SM 500 E KETTLE10N RD. LOP CA 96210 CwWabrs Phar: 6.Transporter i C-Wy Name U.S.EPA ID Number 7.Transporter 2 Company Nemo U.S.EPA ID Number 8.Designated FK*ty Name and Site Address U.S.FPA ID Number W R TECMlOL00tES CORP. YLE AICA 90069 F sPbaw 02=4600 C A D 0 9 703099 3 ga. 9b.U.S.DOT Dnoripdan(hdudrg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Padap Group(t any)) No. Type Quantity WOM. 13.Waste Codes 1. NON-RCRA HAZARDOUS WASTE, SOLID(OILY ABSORBENT) DM Z 2. 3. 4. 14.Special Handling Instructions and Additional Irtamabon •PROFILE*9B 1 :API& B OIL 1-101k ABSORBENT 90.86%•POP Al06•APPROPRIATE PERSONAL PROTECTIVE ECUPWENT 1 1 _ a, 0 3 15, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this corraigrurrM are fully and accurately described above by the proper shipping name,and ars classified,packaged, marked and labeledfplacarded,and are in all respecfs in proper condition for transport according to applicable international and national governmental regulations.H export shipment and I am the Primary Exporter,I certify That the content of this cmPgrxnent conform to the terms of the attached EPA Admowledgment of Consent I certify that Bte waste minimization statement identified in 40 CFR 262.27(x)(ff I am a large )or(b)(if I am a small quantity generator)is true. MvOlferora Printe&Typed Name ` Month Day Year li�j IT--( S%fin 0 1'j 2-J LLML ".0 J 16 Shipments ❑Import to U.S. ❑Export from U.S. Pal of entry/ext: Transporter signature(for exports only): Date leavina U.S.: 17,Transporter Adcnowledgrneol of Receipt of Materials Transporter 1 Printed/T S' Month Day Year a e/ i� o7 Transporter 2 Pdn yped Name Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Altemate Facility(or Generator) U.S.EPA ID Number Faclity s Phone: 18c.Signetura of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Medved Codes(i.e.,codes for hazardous waste Irsabment,disposal,and recycling systems) 1. 2, 3. 4. r F!led Faality Owner or Operator:Certification of receipt of hazardous matenals coyered by the manifest except as noted m Item 18a Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)