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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 Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C L i ir' : i [ JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> JIFFY LUBE 02322 <br /> 500 E.KETTLEMAN RD. <br /> LODI CA 95240 <br /> Generators Phone: ?08 339-0900 <br /> 6.Transporter 1 Company Name U.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 /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICE-CERES <br /> 2920 MORGAN RD. <br /> CERES CA 95358 r A! <br /> Facilit es Phone <br /> ga, Ob.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 Wlivoi. <br /> 1 i <br /> IXO <br /> W <br /> 2 2. <br /> W <br /> C7 <br /> Asbury Entriirop�rtai res <br /> has <br /> as the tlla permits to <br /> 3. r�caNe your was <br /> Our EPA ID NtirerlMrit'iS ►L 060 393 680 <br /> 4. <br /> e <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CUNiACI .-CHEMTREC 1-800-424.9300 ** PPRO-PRIATE PERSONAL PROTECTIVE EQUIPMENT*EMERGENCY <br /> CONTACT CHEMTREC 800424-93 #+00 *TRUCK _ I 1 � <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this coon""siiggnment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in al respects in proper condition for transport 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 6PAAcdmowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> Generptor'slOfferor's Printedffyped Name Signature Month Day Year <br /> -J 16.International Shipments <br /> i- L.1 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.Transporter Acknowledgment of Receipt of Materials <br /> r^> <br /> Transported Pdntedliyped ,' J -` �;:ff ;� %` Signature � `%Month, <br /> ©ay-J�Yeara <br /> r <br /> ZZ Transporter 2 Printedfryped Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 16b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> rai Facility's Phone: <br /> F18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> fS 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 0 1. - 2. 3. 4. <br /> R I I <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Name(` Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR <br />