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'lease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No.2050.0039 UNIFORM HAZARDbUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phonelaniiest Tracking Number WASTE MANIFEST CAL 0 0 0 2 9 4 4 3 9 1 (800}4249300 J J K 5.Generators Name and Mailing Address Generator's Site Address(if dill erent than mailing address) JIFFY LUBE#1478 1648 E. HAMMER LN. STOCKTON CA 95210 Generators Phone: 209 952-8760 6,Transpaner I Company Name U S.EPA ID Numser ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 7 Transporter 2 Company Name U.S.EPA ID Number 8 Desigrated Facility Name and Site Address U.S.EPA ID Number EVOQUA WATER TECHNOLOGIES LLC 5375 SOUTH BOYLEAVENUE LOS ANGELES CA 90058 C A Q 0 9 J 0 3 0 9 9 3 Facility's Phone: ga 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wl.Nol. C 1 NON-RCRA HAZARDOUS WASTE,SOLID,(BRAKE LATHE SHAVINGS) 352 i z 2. w � ! I 3. 1 �I r — I 4 l 14.Special Handling Instructions and Additional Information EMERGENCY CONTACT:CHEMTREC 1-800.4249300 NAERG#961:171 *PROFILE#961: P207425 BRAKE LATHE SHAVINGS *PO#A110225791 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT,1a0� 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately 8mcnibed above by the proper shipping name,aril are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary Exporter,!certify tha!the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent: I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. lors/0 rots Plint ypeName S Menth Day Year na -/G ab ai Shipments ❑Import to U.S. ❑Export from U.S. Port of enirylaxit: _ Z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Y Trans f 1 Prinled/ryped N Signature Month lI Day Year Q T iter 2 Pr ntedliype Name lure Month Day Year Y 18.Discrepancy 18a.Discrepancy Indication SpaceLj Quantity El Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number. 1@b.Alternate Facility(or Generator) U.S.EPA ID Number J_ Q Faciii Phone: L 18c.Signature of Anemate Facility(or Generator) Month Day Year 1 z 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) j 1 2. 3. 4, 20.Designated FacNi Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a Printedrryped Name Signature Month Day Year PA Form 8100-22(Rev.3-05) Previous editions are obsolete. DESIGNA i ED FACILITY TO DESTINAI ION STAT E (IF REQUIRED)