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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />* <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />0 i} 0 iI `i s'. <br />2. Pae 1 of <br />9 <br />1 <br />3. Emergency Response Phone <br />g <br />'300) <br />4. Manifest T_ rackin Number <br />fy'�� "• 4 Tracking <br />0 5 <br />WASTE MANIFEST <br />:= A L i7 ., . <br />4•�? -s tf{} <br />r iJ o. �4., 4 JJK_ <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />JIFFY LUBE #W_ <br />113DI�.MMNST' 1I;? e3t�ST <br />raf NTPECI . CA % tv %TELA a, <br />Generator's Phone: 2M 22 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ASB1. RY EN IRONW-NTX. SERVICES.. C A D 0 2 8 2 7 T 3 t• <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 />Rt4iif)S ENMRONWNT L <br />1595 SOUTH RIV1E�,R ROAD <br />XEST C A ti 0 4 4 0 Q 3 5 �s 6 <br />Facility's Phone: P 95)'37' -5747" <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. <br />NON-RCRA RAZAR )LIS W STE, LIQUID (OILY WATEP) <br />Z <br />2. <br />LU <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information <br />NAERCO 9011 : 171 ' PROFILE #fi 901: 'R ADDI TIONAL EPA CODES : 981 ' , 14014E ' .AfiPR,'."'RIATE PEkSC.l1Vf L PRC)',r_-GTIVE <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare 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 international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />1 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. <br />General es/Offeror'"; int dIT ped Name 7 Sign re Month Day Year <br />r,;k <br />�-- <br />j <br />►- <br />16. Internallnal Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): - Date leaving U.S.: <br />Or <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printedfryped Name Signature Month Day Year <br />O <br />t I ! i <br />QTransporter <br />2 Printedfryped Name Signature Month Day Year <br />H <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 />U <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />O <br />1 . e /� f <br />2. <br />3. <br />4. <br />20. Designs d Facility Owner or Operator: Certification of regeipt of azardous materials covered by the manifest expept s noted in lj#m 18a <br />Printped N m� .- • Signature pr . f , ' Month Day Ye <br />I - <br />- - A. :.f <br />EPA Form 8700-22 (Rev. 3-051 Previous editions are obsolete. n=Q11_K1ATFn Fef_II ITV Tn f1. =rJF:QATnR <br />