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017791548JJK <br /> PIP. so punt or type (Form designed for use on elite(12-pitch) writer.) Fdnll Approved OMB No.205DW39 <br /> UNIFORM HAT.ARDOUS 1.Oenerdtor ID Number 2 Page 1 or 3.Emergency Response Phone 4.Manifest roc ng Number <br /> WASTE MANIFEST CAL 0 0 018 2 6 4 5 1 (800)424-9300 017791548 JJ K <br /> 5.t3miernbx's Nene e a W Mdllrg Addiem 1;enem10ra Site Address(d dnMerent than maisng address) <br /> JIFFY LUBE#2322 <br /> 500 E.KETTLEMAN RD. <br /> LODI CA 95240 <br /> Generator's PMne: 209 3390900 <br /> 6 TransporW 1 Gompany Name U.S.EPA ID Number <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Tranepor1w 2 CaNmy Name US.EM 1D Number <br /> e.Designated Fadlty Name and SReAddross U.S.EPA ID Number <br /> US ECOLOGY VERNON INC <br /> 6375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD097030998 <br /> Fac s Ptama (A23)27 7-1500 <br /> go. 9b.U.S.DOTDosciipdon(indudN Proper Shipping Name,Hazard Claae,ID Number. 10 Containers it.Total 12.)Mit 13.Waste Codes <br /> HM end Packin9cquuP(dany)) No. Type Quantity WtNd. <br /> oa 1' NON-ROM HAZARDOUS WASTE.SOLID(OILY SOLIDS) �v 352 -- <br /> DM P IJ <br /> w <br /> W 2. <br /> O <br /> 3 <br /> 4. <br /> 14 Spedsl Handing kutuctions and Addibor d Information <br /> EMERGENCY CONTACT;CHEMTREC 1.800-424.9300 NAERG#9B1:171*PROFILE#961:AP167298 OILY SOLIDS <br /> P500-00038651*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 230 <br /> 15. GENERATOR IWOFFEAOR'S CERT*XAT10N:I hereby dedere efat ria contents of Res coneigrtmerg are"and accurately described above by 1he proper shippiN name,and am dasslfied,padtped, <br /> raked and lebeledlplacardod,and are In all respects in proper condition for transport according to applicable Intamad"I and national govemmontO regulations If exporl shipment and I am the Primary <br /> Exporter,I certify that to Contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br /> I ocr*tel tla waste minimization statement identified in 40 CFR 262.27(s)(d I am a large quantity generator)or(b)(e i am a$roes quartet'g—tef)is true. <br /> �� w a Pdnmdfrypad`q % Yew <br /> 16.Inkmsta,d ftmeft <br /> RImport to U.S. <br /> J ��Export from U.S. Port of ertryledt: <br /> i- l_..1 <br /> Itanspater w9na4ta ON exports only)'. Date 104vm9 U.S.: <br /> 11.Transporter Admow/edgm emu of Receipt o1 Materials <br /> 0 Trarusporkr t Prkded/fypad N�mq J, SgnWue Day Y <br /> O <br /> Za lrramipmW 2 PQ yped Name S00ife Monet Day ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quanf(ty LIType U Reswua L..I Partid Rejection ❑FuH Rejectbn <br /> Manifest Reliarance Number: <br /> tet.Alternate Fadwy(a Gwwftw) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> in <br /> ISc.SigrmheoofAeemateFacility orGener,tor) Mone+ Day Yew <br /> z <br /> ti19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treabnenl,disposat,and retydfng systems) <br /> q 1 2. 3. 4. <br /> tj20.Designated Faaky Owner or Operator.CadfIcation of receipt of hazardous materials coveted by the manifest exeepl as noted in Item 18a <br /> Pdradnyped eSgnature Month Day Yew <br /> At(, I J �� <br /> EPAFarn87OG-22(Rev. 05) Previous editions dre obsoleTe. DESIGNATED FACILITY+O' DESTINATION STATE (IF REQUIRED) <br />