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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 Responso Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST C A L, 0 0 0 :1 S ' G r.( C' 1 (800 ) 424-3300 018 2 3 3 7 21 JJ K <br /> 5, Generator's Name and filaliin ( 1dress Generator's Site Address (it different [hall mailing address) <br /> JIFFY LUBE ; `?e1J1 <br /> 1471 SHORE SI' 4716 N . 14VE ST LANE MIONTHLY BILLING <br /> WEST SA', �t :AIvIENTC, <br /> Generators Phone; <br /> 209 9521euo STOCKTON CA 902 :1U <br /> 6. Transporter 1 Company Name U,S:' EPAID Number <br /> CAD 0 '_ B 2 7 7 0 3 6 <br /> ASBURY NVIRONMENTAL SERVICES <br /> I <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 /> ASBURY ENVIRONMENTAL SERVICE _ CERES <br /> 1920 MORGAN RD . <br /> CERES CA 95358 CAI- 000393680 <br /> Facilrhj s Phone: 209)5414825 <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WtNol. <br /> 1 . NON-RCRA HAZARDOUS VIASTE , LIQUID ( OILY 1rV AJER ) <br /> 0 0 1 G <br /> LU <br /> 2' <br /> i <br /> 3. <br /> 4, t <br /> 1 <br /> 14. Special Handling instructions and Additional Information <br /> EMERGENCY CONTACT : CHEMTREC 1-800-424 -9300 WOES TERMINAL: CERES 'c � PR PRIA: G�EP R !, NAL PROTECTIVE <br /> EQUIPMENT " EMERGENCY CONTACT CHEMTREC 300-424-9300 x TRUCK # !/J <br /> 16, GENERA'it.)R'SIUFFERCrR'S CERTIFICATION: I hernhy tlt:chrre !flat Aro uvntents of this cansrgnment are fully and accurately doccilbod above by the proper shipping name, aril am d1rWhed, packaged, <br /> marked and labeledlplacarded, 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 Pniaary <br /> Exporter, i certify that the contents of this consignment conform to the terms of the attached EPAAcknov4edgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if i am a small quantity generator) Is true. <br /> Gene ! Ifar� dniedny arae For <br /> Mnnitr DayY 61 d <br /> ==I 16. n v Ilonai Shipments ❑ <br /> u Import to U .S. Export from U .S. Pad of entry/exit: <br /> F- <br /> Transporter signature ((or expolis only): to leaving U.S <br /> 17. Transporter Acknowledgment of Receipt of Materials <br /> LU Transporter 1 Pdntedffyped Norma Signal ✓ ihr Cjayr Y�as,/ <br /> rn '` <br /> Transporter 2 Printed/Typed Name ( torture Month Day Year <br /> F-- <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 /> V <br /> r¢r. Faclity's Phone: <br /> LU 18e. Signature•. of Ailomate Facility (or Generator) Month Day Year <br /> Q <br /> N19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, Mposai, and recycling systems) <br /> 0 2. 3. 4. <br /> 120. Desigru-rted Facility Owner or Operator: Certification or receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdnledfTyped Mame Signature > Smith Day Year <br /> Form 870M2 (Rev. 3w05) Previous editions are obsolete. � — � t:;VACiV4ATE0 FACILITY TO DESTINATION STAT E (IF REQUIRED) <br />