Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manffest Tracking Number _ <br /> UNIFORM HAZARDOUS ; q L 0.0 0 2 9 4.4 3 9 (300)424-9300 � � J K <br /> WASTE MANIFEST �„�, Y J <br /> 5.Generators NaLUBE vaMl�Tdd� Generator's Site Address(if different than malling address) <br /> JIFFY1648 E.HAMMER LN. <br /> STOCKTON CA 95210 <br /> Generators Phone: 209 952-8760 <br /> 6.Transporter 1 Compan�yy Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD097030993 <br /> Facility's Phone: (323)277-1500 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class ID Number, 10.Containers 11.Total 12 Unit <br /> HM and Packing Group(•d any)) No. Type Quantity wt.Nol. 13.Waste Codes <br /> t. Ft?ti-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS,PAPER FILTE ) l <br /> 0 1 � <br /> DM P <br /> Z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 7-" <br /> EMERGENCY CONTACT:CHEMTREC 1800 X1249300 . ROO 981:171 *PROFILE#9B1:AP19S195 OILY SOLIDS,PAPER <br /> 004 <br /> FILTERS *1`800.01595*APPROPRIATE PERSONALWTECTiVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(01 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offeroes Printed/Typed Name Signature Month Da Year <br /> � s <br /> j 16.International Shipments <br /> ll�- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LX 17.Transporter Acknowledgment of Receipt of Materials <br /> F' Transporter 1 PrinteV4iad Name { Signature DayM r6 J� <br /> QTransporter 2 Printed yped Name `` Signature Month Day f Year <br /> IncH <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> C� <br /> LL Facility's Phone. <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> co 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> LLIC3 1 , 2. 3. 4. <br /> i' 1 1. <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 Month /Day Year <br /> r <br /> EPA Form 8700-22(Rev.'3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />