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Reese print or type,(Form designed for use on elite(12-pitch)typevidter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2{Page 1 of 3.Emergency Response Phone 4,Manifest Tfackiumber <br /> WASTE MANIFEST C A L 0 0 0 1 8 2 6 4 5 1(1300) 424-9300 0095'16320 JJ K <br /> S.Genemwtrt�e ff�f �Ilifdress Generator's Sita Address Of different than mailing address) <br /> 600 E. KETTLEWN RD. <br /> LODI CA 95240 <br /> Generator's Phone: 209 <br /> 339-0900 <br /> e,Transporter 1 Company Name U.S.EPA ID Number <br /> ASBURY ENVIRONNENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name OCT 2 3 2014 U.S,EPA ID Number <br /> 8.Desigpated.Eaci 016100 me and Sle Address U,S.EPA ID Number <br /> 7300 CHEVRON WAY ENVIRONMENT�� HEALTH <br /> DIXON OA 90 DEPARTMENT C A T 0 8 0 0 1 2 6 0 2 <br /> Facdl s Phone: (7071693-M(7071693-M552 <br /> ga, 9b,U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total Q.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 7. <br /> 0 NON-RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) 001 T T d G <br /> 9 <br /> ru <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.SpecialHandfi insiru ons and Additional In lion <br /> NAERN 981 : 171 *PROFlLE#981 : M 10442'ENEROENCY CONTACT:CHEMI REC 1-800-424-9300'ADDITIONAL EPA <br /> CODES:991 : ,NONE"APPROPRIATE PERSONAL PROTECTIVE EQUIPIVENT <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cons!gnmenl are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled(piacarded,and are In al respects in proper condition for Vansport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I car*that the waste"rymization slatemenl{dentifled In 40 CFR 262.27(a)(i(I am a large quantity generator)or(b)(f I am a small quantity generator)is We. <br /> Genera slOHefoes Printedlryped Name Signature Month Day Year <br /> c e r hdr �z a f z <br /> r 16.Inlema Lional Shipments <br /> r— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAdmo iedgmenlofReceiptofMaterials <br /> Transporter 1 rintedrTyped Name f� J f Signature Month Day Year <br /> F— Trans rtr 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fug Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> J <br /> U <br /> ii Facility's Phone: <br /> W 18c.Signature ofAifernate Facility(or Generator) nth Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(I.a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator.Certification of recelpl of hazardous maledals covered by the manifest except as noted In Ilem 18a <br /> Printed(r ed Name S nal Mon Da Year <br /> j ?Ll 6LJ eldoZA az o5 1/Z <br /> E?A Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />