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RECEIVEf <br /> OCT 0 5 2015 <br /> Please print or type.(Form designed for use on elite(12•pilch)typevrbler.) Form Approved,OMS No.20500039 <br /> UNIFORM HAZARDOUS 1.c me abr 1U Nmnbcr 7,,e�gq HK e c n 4.Manlfost Tracking Number <br /> WASTE MANIFESTN H 014052571 JJ K <br /> 5.Genera!oesNamsand Ma.`ngAddress _00 -182645 — --_ ( (enllhanma'I:Naddress) <br /> 1IFrY LUBE X02322 <br /> � <br /> 500 E.KETTLEMAN RD. CA 95240 <br /> Genera!ofs P 0: 209 339-0900 - <br /> G.Tfanspodes I CompanyNama U.S.EPA IDNumNf <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 9 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des�gnaled FaCdyXXNaamm�e and Silo Address U.S.EPA 10 Nbmber <br /> ��6KI' VRON WAY <br /> Q��SON CA 95620 C A 0 8 0 012 6 0 2 <br /> Faci',ly's Ph 7n-7t�+ Qn <br /> 9, 9b.U.S.DOT Descq,w)((iin'c'1"Ong Proper SIVPP'N Name,Hazard Class,tD Nu nbar, to-Conidws 11,Total 12.Utol Ig,4Yaste Codes <br /> Ht,1 and Packtnl Group tit any)) Ro. Type Quantity 4111VL <br /> 1. <br /> o NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER) 0 O± T T G 223 <br /> w <br /> z 2. <br /> w <br /> 9. <br /> a. <br /> 14, peclaiHand:ngrnstnicionsandAdd.t'onal!nformal;on <br /> NAERGN 991!171 a PROFILE N 991!DI(110442 *EMERGENCY CONTACT!CHEMTREC 1-800-424-9300 y <br /> ADDITIONAL EPA CODES;981:,NONE a APPROPWATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contonlsof th's cons'gnment are ruiY and aavrate7y descdhed abm-e by the proper sh!pp`.ng name,and are dass;Ted,packaged, <br /> marked and labe'edtp'acarded,and aro In a'1 respects in proper coM:Con for transport accord'ng to app',InlernaFonal and natonal govornnlentat reguratons.II a%Mt sh'pmerA and I am the Primary <br /> Exporter,I cel ity that No contents of Wscons:gnmeni conform to the terms of No aniched EPAM(wsledgmenl of Consent. <br /> I cerUly that the ssaste m dmizaron slafement fdentiLad In 40 CFR 2G22Ila)(if I am a largo quantity generale)or tb)(if l am a smart quantity generale)is wo. <br /> Generatofs'OHarofsPdnledRypedName S'.gnalurci `! I.;onth Day Year <br /> j 10.Inwroat,orwl Stdpmenls ImPM to U.S. pd <br /> ENport Irani U.S. Pori of en fex4: <br /> 6— Transporter s'gnaluro((or axparis arty): Data leav'asg U.S.; <br /> w 17.TranspoderA0uwA:edgrnenlofReceptollra!erias <br /> Transpode7111Atod1ZPNAQl8 Signa!vfeh!onN Day Year Month Day Year <br /> 2Q r spoder'2Pn fryped NaniTSignature <br /> I$.Discrepancy <br /> Iiia.0iscrc•pancy Indication Space Guanbty ❑Type ❑Res'due ❑Panal Re•'%Von ❑Ful Resection <br /> Nar6(est Reference Number. <br /> 18b.Nlornate Fac!.ly(or Cenera!or) U.S.EPA ID Number <br /> V <br /> ti Fab!:tyrs Phone: 'Mont Day Year <br /> 0 18c.Signature of hllernale Fac',ty(or GeneraV) <br /> �s <br /> z <br /> Nto.Hazardous W.We Report Management method Codes(i.e.,cr rI3 W(hazardous rras!o treatfnenl,dsposal,and recycr'ng systems) <br /> 3. 4. <br /> 20.Oes gnaled Padrity Onner or Opera'a:Cert faaGon of rtto'gl of hazardous materials cos eyed try U!e man7esl oxtopl as Med in Ilam 18a <br /> PriWodfl}psd Namo Signa ,} <br /> h.onW ay year <br /> EPA Form 8700-22(Rev.3.0 ) Pr viousedilionsamobsoVe. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />