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Please print of type.(Form designed for use on elite(12.Och)typewriter) Form Approved.OMB No.21 <br /> UNIFORM HAZARDOUS 1 GenemwIDNumber 2.Page 1of 3.EmergencyRespormePtwne 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 01 1 0 3 2 1 (800)424-9300 1013079066 J J K <br /> 5,Generalor s Na me and MaTing Address Generators S;4e Address(d dfferenl than maN address) <br /> JIFFY LUBE X98 <br /> 9.330 N.MAIN ST 1130 N MAIN ST <br /> MANTEC,A CA 95136 MANTECA CA 93336 <br /> Generator`s Phone: 209 239-OGGE ) <br /> 6.Transporter 1 Company Name U.S.EPA ID Number I <br /> ASBURY ENVIRONMENTAL SERVICES ICAD028 2770006 <br /> i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S <br /> 8.Dedgna!ed FaPGIy Name and Si!eAddress U.S.EPA ID Numbar <br /> DK DIXON <br /> 7300 CHEVRON WAY ) <br /> DIXON CA 95620 I <br /> FacIII cjs Phow (7071693-6009 ICATO8OOi26O2 <br /> ga Bb.U.S.DOT Desuiplbn(induti q Proper S3tppag Ham,Hazard Class,ID Number, !o.Conta'ners 11.Total 12.Unit 13.Waste Codes <br /> Fttd and PackR%G(oup(farry)) No- Type Quantity VArVoI. ' <br /> 0 1• NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER) 0 0 i TT G 223 — <br /> 2. <br /> 5"0 <br /> 1 ---� <br /> RECL <br /> , <br /> �. JUL 2 7 2017 -- <br /> 4. ENVIRONMENTAL HE NLTHf <br /> DEPARTMENT <br /> 14.Wal RandSng fnstrucCdns aMAdd tonal Informai <br /> NAERG# 9131:171 X PROFILE#9131:DK100ii0 "EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 * I <br /> ADDFRONAL EPA CODES:Mi.-,NONE *APPROPRIATE PERSONAL PROTECTIVE:EQUIPMENT <br /> 7AUJI 4f 10,U <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: IIwebydetfarethat thocontents ofthSwns,grvwtare fuiyand acwta!tidescnbedabowbythoproper shpp'ngname,and aredassifred,pack*, <br /> marked and labe'sdlp acarded,and ace in a9 respects In proper wnd,6on for bansport acoading to appELab'e tnlew6ortal and national governmental rgvIai if erpat sh'pmenl and lam the Primary <br /> Expotler,I certify,that the contents of 1Ns conslgnmeM conform to Ura terms of the atlachad EPAAwrowiedgmeet of Consent. <br /> I certify Ihal the waste rremmizaEon slatemenl identified in 40 CFR 262.21(a)(d I am a large quantify generator)or(b)(if i am a sma'I quari gerxfaloc)is true. <br /> Genera Qesslofferoes Printe'VType`d Name Slgrta / / r K"wth Day Year <br /> t6.lntornatlonal Shipments I <br /> ❑Irrtiport to U.S. U Export from U.S. Purl of enlry;erit <br /> Transporter signature(tor e)poris otx<): Date feaving U.S.: <br /> w 17.Transporter Ac saAtedgmeni of Rece?pf of Materiats <br /> r Transpaler I Prinfed'TypedNarno Sigraturo l.'Qnth Day Year <br /> af <br /> QTransporter 2 PrintedrTyped Name S gnaNra Month Day Year I <br /> 18.Discrepancy <br /> 18a,Dscrepancy IndicalfOn Space L1 Quarivy ❑Type I I ReSV. ❑Partial Reorlim ❑Ful ftejecGon <br /> Manifest Reference Number: <br /> 181 Allemale Faaty(of Generfi U.S.EPA ID Number I. <br /> U <br /> U- Fadliy's Phone: <br /> 18c.S,nMjfe ol'Ahemate Faddy(cf Gergrator) hvth Day Year <br /> zz <br /> 1g.Hazardous Waste Report Managemenl Method Codes(Le.,codes for hanrdow waste treatment,disposal,and fesyd?rg systems) <br /> � 1. �\� 2. 3. 4. <br /> f <br /> 20.Designated Fadtity Qaner or Operates:Certfration of receipt of hazzrdous matcrWs coveted by tho manifest except as no h Rein l8a <br /> Proted/TypcdName SgnaNre htorth Day Year <br /> t� 166 <br /> �7 <br /> EPA Form 8700.22(Rev.3-05) Pi drditronsare obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED} <br />