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PleaserMIT711i(Form resigned for use on elite(12 Ich)lyPewnler. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenemIw IONambm 2.Page 1 of 3.EmergencyRespoirse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 2 9 3 3 6 3 1 (900)4249300 1 014055178 J J K <br /> S.Generator's Name and Mailing Address Gerrerebls Site Address to amerent than mailing address) <br /> PRO LUBE INC #102 <br /> 808 S. CHEROKEE LN. <br /> LODI CA 91240 <br /> Generators Phone: 209 333-2744 <br /> 6.Transporter 1 Company Namea .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 /> B.DesignatedFacility Name and SIIeAddless U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD097030993 <br /> Faciff Is Phone: (323)277-L500 <br /> ga SO.U.S.DOT Description Qndudhg Proper Shipping Nemo,Harard Class,ID Number, 10.Contalnere 11.70tel 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) N. Type Quantity WL/Mol. <br /> I- NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) 352 <br /> 0 D N /a v P <br /> z z <br /> E <br /> 3. A <br /> LL <br /> 4. ENV RCNM NTAL <br /> FT71 IT 7"w" <br /> 14.Special Handlbg Inst=*m andAddhior l inW=l <br /> EMERGENCY CONTACT: CHEMTREC 1-8004249300 NAERG#9B3 : 171 *PROFILE#951:P208658 ABSORBENT, RAGS, <br /> PAPER OIL FILTERS,OIL. DIRT, DEBRIS *P500.00019313 -APPROPRIATE PERSONAL P OT CT VE EQ IIPP`M'J Tj Z316 a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ere fully and accurately described above by the proper shipping name,ani are classified,packaged, <br /> marked and IabeledfpQcarded,and are In a0 respects In proper condition for transport according to applicable Intematioroland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cedlfy that the contents of this consignment conform to the terms of the attached EPAAclrnowled9ment of Consent. <br /> I certify that the waste minimization statement Identified M 40 CFR 262.27(x)(It I am a large quantity generator)or(b)(NI em a small quantity generator)Is we. <br /> GeneratorivOBerar;BrlJ led/Typed Name Y Sgwture Month Day Year <br /> %/ 30 <br /> J 18.International Shipments <br /> import to U.S. LJ Export from U.S. PON olemrylexit: <br /> Transpodw signature(for exports o*y. Date leaving U.S.: <br /> Ot 17.TranspoderAcknowledgmeni of Roe*of Materials <br /> Tra r 1 Printetl/Typetl Name SignatureWorth/� J <br /> elf.eZ Transporter 2 PdntedRyped acne ture Month Day Year <br /> a <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ aanuty ❑Type ❑Residue ❑Per6al Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 186.Alternate Facility or Cenamor) U.S.FPA ID Number <br /> J <br /> U <br /> LL Elici s Phone: <br /> w 18c.5ignature of Nlemate Facility(or Generator) Mnrm Oay Yex <br /> z <br /> 19.Hazardous Waste Report Management Method Coda(Le.,codes for hazardous waste treatment,disposal,and racycllrg systems) <br /> 1 2. 3. 4, <br /> 20.Designated Facility Dwndr or Operator.Certification of receipt of hazardous materials covered by the manifest except as Med in Item The <br /> 1 Prinladlfyped Name Sigrahae Month Day Year <br /> IL <br /> EPA Form 8700-22(Rev.3-05) previous editions are obsolete. DEsrGNATED FA TO DESTINATION STATE (IF REQUIRED) <br />