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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved,OMS No.2050.0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 12, <br /> Page1of 3.Emergency Response Phone 4.ManifestTr kin Number <br /> WASTE MANICA L 0 0 0 1 8 2 6 4 5 (800) U'-9,300 0 0 95 16 3 2 4 J J K <br /> 5.Cenerap"ILTV w0wress Generators Site Address(Idifferent than mailing address) <br /> 600 E. KETTLEMiW RD. <br /> LODI CA 95240 <br /> Generators Phone; 209 33940900 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name 2014 U.S.EPA ID Number <br /> 8.Deslgpa(gd.Eacilih kme and Silo Address ENVIRONMENTAL HEALTH U.S.EPA ID Number <br /> UD13 ONHEVRON WAY CA 95620 DEPARTMENT <br /> CAT 0 $ 0 0 1 2 b 0 2 <br /> Facility's Phone: 17071693-6008 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.7otal 12.Unit Q.Waste Codes <br /> No. Type Quantity WuVof. <br /> HM and Packing Group(If FY)) 223 <br /> 1. <br /> o NON-RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) 0 0 1 TT Zrj <br /> LU 2. <br /> w <br /> 3. <br /> 4. <br /> 14.speNdaAtERQ119Bi 171`PROFILE#9B1 '. OKIi0442'EIVERGENCYCONTACT.CHEMTREC 1-800-424-9300'AD0I110NAL EPA <br /> CODES:9Bi ; ,NONE'APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this cornstgnment are fully and aaurately described above by the proper shrpping name,and are classified,packaged, <br /> marked and labeledlptacaided,and are in all respects In proper condition for transport according to applicable Wernationaiand national governmental regulations.If export shipment and I am Una Primary <br /> Exporter,I cortffy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(it 1 am a large quantity generator)or(b)(III am a smafl quantity generator)Is We, <br /> Genera erors PrintedlTyped Name Signa MoNh Day Year <br /> uz LW-J 16.In al S pmfl Is ❑Export from U.S. Part of entryle)dl: <br /> ❑Import to U.S. <br /> z Transporter signature(for exports only): Dale leaving U.S.: <br /> M 17.TransporterAcknoMedgment of Receipt of Materials <br /> Transp er 1 Priniedriyped Name Signature Month Day Year <br /> I IU� n� rj (akwXy Mo is <br /> z Transporter 2 Prinled7Typed Name Signature Month Day Year <br /> F-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Ir4catlon Space Quantity ❑Type ❑Residue ❑Par6at Refection El Full Refection <br /> Manifest Reference Number, <br /> i8b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> c� <br /> FacUity's Phone: onih Day Year <br /> w 18c.Signature of Alternate Fads (or Generator) <br /> a <br /> 1Z <br /> 2 19.Hazardous Waste Report Management Method Codes 0.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 0 1. , / 2' <br /> 20.Designated facility Omer or Operator Cerlificawn of receipt of hazardous maledals covered by the manifest except as noted in Item 16a <br /> PrinledrTyp/ed Name Signature Month Day Year <br /> J1 L vt oe <br /> cPAform 8100-22(Rev.3 05) Previous edi(ioris areabsolete. DESIGNATED AGILITY TO DESTINATION STATE(IF REQUIRED) <br />