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016869556JJK <br /> prial or type. Fan dost ned tot use on she 1 r. Fo m Approved.OMS No.2050-0039 <br /> UM{FORA(HAZARDOUS 1' Wr <br /> r 2.Pape 1 d 3.Emerper y RR%w m Ptwre 1.Mantled TrwAhV lumber <br /> WASTE MaNIFEST I CAL 0 0 018 2 6 4 6 i 800 424-9300 016869556 JJ K <br /> 5.C7enrr 4 Name and Mmmg Adeteca tswwotors Sae Addaae in omowt ff m ma"so"") <br /> JIFFY LUBE#2497 <br /> 730S.BECKMAN ROAD <br /> LODI CA 95240 4715 N.WEST LANE MONTHLY BILLING <br /> cWwrowe Puma: 209 952.1662 <br /> 6 Trr-,grAw 1 Corrmparty Noma U.S.EPA ID Nxrmtwr <br /> ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7 Tranetnttee 2 Ccxnor y Name U.S.EPA ID Number <br /> e.Designalad Fadity Name and SAO Adbeas U.S.EPA ID Nu iw <br /> US ECOLOGY VERNON INC <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 097030993 <br /> FwAtys Plume: (394977-15W -- -- <br /> ga. 9b.U.S.DOT Deaatpdon(r4Udng Props Wpp)rp Nome,Huard Class,10 Number, 10.Cattaawre 11.Taal 12.Urd 13.woote Codee <br /> HM and PKOV Drag(f")) No. True Quan@ty mrwt <br /> 1' NON-RCRA HAZARDOUS WASTE,SOLID.(OILY SOLIDS-PAPER FILTERS j ! -1 <br /> i D IV P <br /> W 2 <br /> (7 <br /> 3. <br /> 4 <br /> 14.Spmdd Hrd irdMOWM and Addnfortal WOrMilon <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 NAERG#961:171*PROFILE#961:AP 192210 OILY SOUDS•PAPER <br /> FILTERS*P500.00030575*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15 OEWPATORWOFFEROR'9 CERnMATION:I hr,eby dedare*al dw oonlents d this oauigr mart am A!y and aoxm*desorlbed above by tlta pmpr stiXirg nano,and ata des+lkd.Ppodrapsd, <br /> naked rid labeled/ ouided,and are In al respects in proper oond dw fix tranmport Doxy&p b apptrabb kascrmaftW and milord grnommertdl mgublb*0 export at*rmera ane I am the Pr nary <br /> Eq=W.I cantly fiat lie rardent of t is rnmdgrmwrd=dam b the bmme d Iw attached EPAAdwA,d�of con"M. <br /> I cem9y Smut ff*waste mWmkat$on dsteowd berMed In 40 CFR 282.27(x)rd I am a lave gtwmety wwekx)or(b)(U I em a smell guan*{}rrmaatx)Is bus. <br /> GanenbralOM1aa-LM s Nemo Shy is uo MM61 Dey Year <br /> 119 r #%0G- k loy tz(y I18 hiammorw&Vrarft � <br /> ❑+ bU.S. ❑EKpWlromUL/ Pond = <br /> Trrmeparlar slpna-(Nr orpats oNy}; Done leaft U.S.: <br /> 17.Trro"WAMWAodgmW of Reo*d Malefts <br /> T 1 ypod Nana Sigurb Mon* Wy Yam <br /> Irc t trs- I c JOY 12 "r I /7 <br /> Tram"tor Signature Mram Day Year <br /> 18.D+sruenency <br /> 182.Disaapvxy IndaMbn Specs ❑ y ❑Type ❑Re wua ❑Partld R"ocbon ❑Fu1 Re)eceon <br /> Mrrfeut Reference Number: <br /> 18b.NtonWa fackty(a Gonrabr) U.S.EPA ID Number <br /> V <br /> Fedky's Phone: <br /> u9 IS&SoWum of Nw.rt>ato Faalay or fAxittm Day Year <br /> Z <br /> 1!.Haawdomo waste Report Menepem«mt Method codes(i.a.,000ee br hazardous waste tteetrord,dapoar,and racydng rtwmro) <br /> wn 1. r <br /> 3. 4. <br /> 20.Devnalod Owner or Operator C rbitratbn of roce+p(d hazardous nmelorfols covered by ae man*Nd emapl as noted In them 150 <br /> Signatum Mom rMl Now <br /> 6Z <br /> EPA Form 87W22(Rev.3-05) Proviouc editne are obsrlleta. DESIGN A FACILJTY TO DESTINATION SPATE(IF REQUIRED) <br />