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Please peril or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST r.A n 0 0 1 8 2 6 4 i 8(101 4249300 014053429 JJ K 5.Generalors Name and Mailing Address Generators Site Address(it different than mailing address) JIFFY LUBE#2322 500 E.KETTLEMAN RD. LODI CA 95240 Generators Phone: 339-0900 6.Transporter 1 Company Name US EPA ID Number ASBURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 7,TranspWer 2 Company Name U.S.EPA ID Number 0 Designated Facility Flame and Site Address U.S.EPA ID Number EVOQUA WATER TECHNOLOGIES LLC 5375 SOUTH BOYLE AVENUE LOS ANGELES CA 90058 CAD097030993 Facility's Phone: ga 9b.U.S.DOT Desc ption(Inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtJVoi. 1. NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) -152J-11?5� ZAD �.� P z z. NON-RCRA HAZARDOUS WASTE,SOLID,(OILY PAPER FILTERS) _7 D J°ZU P 3, I 4. 14.Special Handling Instructions and Additional Information EMERGENCY CONTACT:CHEMTREC 1-800-4249300 NAERG#9131:171,91322:17010.!**PROFILE#9131:AP167298 OILY SOLIDS,9B2 :AP167298-1 OILY PAPER FILTERS * APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT ZZ .5 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, marked and labeled/placarded,and are In all respects In proper condilion for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. GeneralorslOfferors Printed[Typed Name Signature Month Day Year 16,International Shipments F... El Import to U.S. L1 Expert from U.S. Fort of entrylexlt: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials w Month Day Year Transp r 1 Printed/Typad Nam> Signature O a Z Transporter 2 Printedffyped Name ture Month Day Year a I- 18.Discrepancy 18a,Discrepancy Indication Space Quantity F1 Type ❑Residue ❑Part al Rejection El Full ReJedlon Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S EPA ID Number J U LL- Facility's Phone: w 10c.Signature of Alternate FaclSity(or Generator) Month Day Year Q z L9 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) W 1 2. � % / � 3. 4 20.Designated Facility Owner or Operator Certification of receipt of hazardous ma!erials covered by the manifest except as noted in Item 16a PrintedlTyped Name Signature PAonth Day Yuar ERA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'rT DESTINATION STATE (IF REQUIRED)