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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1 Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST L'11L000182fi45 0179158 JJ�C <br /> i (800)4249300 <br /> 5.Generators Name and Mailing Address Generators Site Address 0f different than mailing address) <br /> .i1FF'Y LUBE#2322 <br /> 500 E.KETTLEMAN RD. <br /> I.ODI CA 95240 <br /> Generator's Phone: 209 339.1804 <br /> 6.Transporter 1 Company Name <br /> ASBURY ENVIRONMENTAL SERVICES U.S.EPA ID Number <br /> 7.Transporter 2 Company Name CAD028277036 <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> US ECOLOGY VERNON INC U.S.EPA ID Number <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CK g005g <br /> Facility's Phone: 323 277-1500 CAD 0 9 7 0 3 0 9 9 3 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Clem,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> 1 NON-RMHAZARDOUS WASTE.SOLID(OILY SOLtI)S) No Type Quantity Wt.Nol. <br /> 352 <br /> w <br /> tZ 2. <br /> t.7 <br /> 3. <br /> a. <br /> 1 Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 NAERG-0 981:171 *PROFILE 0 SBI:AP167298 OILY9�UDS <br /> P500-000386M*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENE RATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifiepackaged, <br /> marked and labeled/placarded,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 Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 /> Generstors/Offerors Printad/Typed Nin S. <br /> 3. 1(��? �� Mon Day Year <br /> V XL,16.Intemational Shipments ImporttoU.S. <br /> ❑ <br /> � Transporter signature(for exports only): ❑Export from U.S. Port of entry/exit: <br /> LU 17.TransporterAcknowledgment of Receipt of Materials Date leaving U.S.: <br /> Transporter 1 Printed/Typed Nama <br /> O �a�` _ Day Yeas <br /> a fes/ ��-L- <br /> z Transporter 2 PrintedrTyped Name Signature <br /> � Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> �Full Peiection <br /> Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑ ! <br /> 18b.Alternate Facility(or Generator) Man fest Reference Number: <br /> -� U.S.EPA ID Number <br /> c� <br /> LL Facifity's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q F:'0n01 Day Year <br /> Z <br /> SR19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C32.. <br /> 2. 3. <br /> L 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name P <br /> Signature <br /> r--� Month <br /> �t Day ear <br /> fi ( d l <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> ESIGNATED FACILITY TO GENERATOR <br />