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Please print or type.(Form resigned for use on elite 12-phch) ter.) Form Approved.OMS 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 CAL 0 0 01 8 2 6 4 5 1 (800)424-9300 016766776 JJ K <br /> 5.Generator's Name rued Mailing Address Generalors Site Address Of different than mailing address; <br /> J IFFY LU BE#2322 <br /> 500 E. KE17LEMAN RD. <br /> LODI CA 95240 <br /> Generator's Ptwne: 209 339-0900 <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 /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD097030993 <br /> FacilisPhone: 323 277-1500 <br /> 9a 9b.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 Of any)) No. Type Quantity WUVol. <br /> Cr 1 NON-RCRA HAZARDOUS WASTE,SOLID, (OILY PAPER FILTERS) 352 I <br /> D P <br /> z 2. <br /> LU <br /> 3. I <br /> 4 <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 NAERG#9131:171*PROFILE#9131:AP167298-1 OILYPA�ILTERS <br /> K P500-00023835*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,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 EPAAcknowledgmonl qf Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262-27(a)(If I am a large quantity generator or )(if I am zysmallwa"A'1041.. <br /> GeneratorsJOfFeror's Prinledfryped N — Signa re Month Day Year <br /> =J 16.International Shipments <br /> r ❑1 to U.S. Export from 6. Portof entry/exit: — <br /> Z Transporter signature(for exports only): Date leav ng U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> LW <br /> Transp 1 PrinledfT ^ Signature Month Day Year <br /> 0CL1O/ 3 <br /> Cn r Month Day Year <br /> ZQ Transporter 2 Print d/fypedName- ature <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Re)ection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 0 <br /> L<- Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> 4 <br /> z <br /> U Cn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by 0te manifest except as noted In Item 1 Ba <br /> LPrinted/Typed Namo 1 I' Signature Month Day Year <br /> \( 1V1 L <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITYfld DESTINATION STATE (IF REQUIRED) <br />