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D T S C.. 0 4,5 2 3 1 G 5,'2.' <br />_ Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 4 0 016 7 1 (800)4249300 018 2 3 7 8 91 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SPEEDEE OIL CHANGE&TUNE UP-GRANTLINE RD - <br /> 245 W. LOUISE AVE <br /> MANTECA CA 95336 711 W. GRANTLINE RD <br /> Generators Phone: 209 836-1557 TRACY CA 95376 <br /> 6.Transporter 1 Company 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 CA 097030993 <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 <br /> and Packing Group('d any)) No. Type Quantity WtNol. 13.Waste(:odes <br /> 1' NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID,PAPER FILTERS) Z352 <br /> o <br /> DMP P <br /> z 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS *PROFILE#961:P209724 OILY SOLID,�/ <br /> PAPER FILTERS *P500-00049937 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT e- I ?:� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper ship ing name,and are classified,packaged, <br /> marked and labeledlplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(•d I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Nam Signature Month Day Year <br /> N Ww Inc© E K Aq TT I S mcovw1 D <br /> a 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAdmowledgment of Receipt of Materials <br /> Transporter 1 Printed/iype Signature Month Day Ye <br /> d <br /> a aa <br /> Transporter 2 Printedfryped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ ) ❑Full Rejection <br /> El Residue Partial Re'ection j <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a ' <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 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 /> Printedrryped Name Signature Month Day Year <br /> 01 0/ 11191 <br /> i <br /> EPA frorfn 9700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12806.1869 <br />