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Please print or type.(Form designed for use on elito(12-pkh)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDo115 I•Genefalor ID Number 2.Page I of 3.Emergency Response Phone �.Manifest TracUng Number { <br /> WASTE MANIFEST. C . 'I 2 ,. goo 424-930 . 013079065 JJ K <br /> 5.Generalors Name and MairN Address Generators Site Address(if different than in utg address) <br /> JIFFY LUBE-##598 <br /> 11.30 N*MAIN ST ii30 N MAIN ST <br /> MANTECA CA 95336 MANTECA CA 35336 <br /> GenemloesPhone: 209 239.0665 <br /> B.Transporter i Company Name U.S.EPA ID Number <br /> ASBURYENYRONMENTAL SERVICES ICAD028277036 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Dssi haled FoaLty New and S:teAddress U.S.EPA ID Number <br /> DI(DIXON <br /> 7300 CHEVRON WAY <br /> DIXON ` CA 95624 <br /> FaPhone: C:ATO80Ui260 ?. <br /> a*t1/s70 693-60013 <br /> ga. W U.S.DOT Oesaiplon(indudng Proper Sh'ppirg Name,Hazard Class,ID Number, 10.Containers 11.Total 12.U6.1 <br /> I1M and Paci rg Group(if any)) 43.Waste Cases <br /> No. Type OuanuTy W1 Not. <br /> 0 I. NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER) 001 •I T 6 223Ll <br /> W 52. <br /> j <br /> RECE V L. Ldf <br /> 3. JUL 27 2017 <br /> 4' ENVIRONMENTAL HEA H1 <br /> DEPARTMENT <br /> 14.Specht Handrag instructions and Additional l6ormation <br /> NAERG# 981:-171* PROFILE#Elft:DK1001t0""'�EMERGENGY CONTACT:CHENITREG 1-800-424.9300 <br /> AD{NTIQNAL EPA CODES:981:,NONE' APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> r -A,;#/ll X3.2 <br /> 15. GEIIERATOR'SIOFFEROR'SCERT(FIGAI[ON:I hereby declare that the conlenIs of this cons!nment are uty and accuiate}l described above ty/the propershlppngname,and are crasifxd,patkaged, <br /> marked and labe'.edfptscarded,and are in al respects In proper condSon for transport accordng to apptcaUo internalwnal and natbnal garernmental regularons.If export sh'pment and i am the Primary <br /> Exporter,I certify that Via contents of this cons.gement contam to the terms of Ike attached EPAAc3uvAfedgmenl of Consent. <br /> I certify that the waste rrirumhaton statement Identified in 40 CFR 282.27(a)(it I am a large quenRy genet' Is true. <br /> Oe erator Offeror's Priioeffyped Nano :gnawa Month Day Year <br /> .� M.international Shipments <br /> ❑lmpodta U.S. El Export Fran U.S. Pori of enlr}sexif: <br /> Transporter s'griatvra(la exports orn'y): Date feaviog U.S.: <br /> 17.TrampoiterAdw.%Ied<jmenlolfte'ploftlatedas <br /> Transporter i PrWedfryped Name Synaturo Month Day Year <br /> � Lk, <br /> Q Transpoder2PrfntedfTypedName Slgoature Month Day Year <br /> 18.01strapancy <br /> 189.Discrepancy Ind'carm Space <br /> Quan6 <br /> ty ❑Type ❑R.W.duo ❑Parlial ft Von ❑Ful Re wiser <br /> Marled Reference Number. <br /> 18b.Alternate FaaLty(or Generale+) U.S.EPA IO Number <br /> U <br /> uQ. F.LIJ3 Phone: <br /> I8c.SignatureofAitemateFacility(d(Generalor) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Managementhle-11 d Codes(Lo.,codes for hazardous waste ueatment,disposal,and recW.N systems) <br /> a 1• 2. 3. 4. <br /> 20.Oestriated Faaity OAner or Operator:CeWtaton of receipt of hazardous materials covered by the manifest ex nded in Hem 18a <br /> 7,inl ,p­ellla- 5lgnatw fonth Day Year <br /> k/5 ' W e <br /> EPA Form 8700.22(Rev.3-05) aviouselflu sareobsolete. DESIGNATED FACILIT O DESTINATION STATE(IF REQUIR D) <br />