Laserfiche WebLink
Please pts or iype.'(Form designed for use on elite 12- Itch ggwwtilor.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency Reapmse Phone 4.fdanifeal Tracking Number <br /> WASTE MANIFEST i 9300 _ 014053429 JJ K <br /> 5.Generalaes Name end hla:Ung Adlws Generators Site Address(If deferent than mailing address) <br /> JIFFY LUBE#2322 <br /> 500 E.KETTLEMAN RD. <br /> LODI CA 35240— <br /> Generator's Ntrwre: I <br /> G,Tnue.rwler 1 Company Prow 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 /> S.Designated Facility Name end Site Address U.S,EPA ID Number <br /> EVOQUA WATER TECHNOLOGIES LLC <br /> 5375 SOUTH BOYLE AVENUE <br /> Facility's PhLOS NGELES r^TT ^^ CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br /> ga• 9b.U.S.DOT Descry'don(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1t,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group IN any)} <br /> No, Type Quantity WLNoL <br /> o NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) <br /> a D r� P <br /> w NON-RCRA HAZARDOUS WASTE,SOLID,(OILY PAPER FILTERS) <br /> 0352 <br /> 1 Dr. :J20 P <br /> 3. <br /> 4. <br /> 14.Special Handling inslructlons and Additional InfameUon <br /> EMERGENCY CONTACT:CHEMTREC 1-800.424.9300 NAERG#981:171,9152:171*PROFILE#0(961:AP167298 OILY <br /> SOLIDS,9132:AP167298-1 OILY PAPER FILTERS* *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT ,62775-\ <br /> 15. GEMMATO MIFFEROR'S CERTIFICAPON:11tw*declare flet ftw oofdanfe of 8tls consignment are fully and acarataly described above by the proper shipping name,and are clatsCmd,packaged, <br /> marked and labeled/placarded,and are In all respects In proper andltlon far transport according to applicable intematlonal ind national governmental regulations.M export shipment and 1 am the Primary <br /> Exporter,I certify Thal the contents of Ihls consignment conform to the terms ON attached EPAAdmo%ledgment of Consent. <br /> I cedlfy that the waste minimization statement Identified In 40 CFR 28227(a)(N 1 am a large quan'lty genoraior)or(b)fill am a small quanaly gc•.noratur)Is True. <br /> (ierraratorslOReraf s priMedrfyped Name 5 gnaturo Month 0.y Year <br /> �- q <br /> r� f-6&y\ © v l <br /> -5 16.Intmrkmi iripmenls <br /> Z ❑Import to U,S. ❑Export from U.S. Port of entrylexfb <br /> Trarrspodrr slgnaAuo(Wr erpats ordy): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp#4r 1 Printedffyped Nan — Kinin Day Year <br /> zd Transporter 2 ProlodfTyped Name grralura 1.1-mlo Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space OuanllV ❑T e ff 11 <br /> YF IJ Rasldue El Partial Redaction 0 Full RslocUon <br /> Manifest Re>iYance Number: <br /> 18b.NUrmale Faciliiy(or Generator) US EPA ID Numbef <br /> J <br /> U <br /> Eocitilys Phow: <br /> wUO The Signaluroo IernateFacAdy(orGenerator) Month Day Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes 0.e.,codes for hazardous waste IrealmenC ttspxal,and recyduq system) <br /> Lij r I —HY / 2. / 3. T <br /> 20.Designated Fadkty Owner orOperator CerBficaUan of receipt of hazardous male savored by the manliest except as ndbd In Item 18a <br /> Iatnte ypcdN.nmaGL1� �` �y��( Signalura J ay <br /> I` o� <br /> 1.1 A form 8700.22(Rev.3.05)Prevkxrs editions are obsolete. DESIGNATED FAcILITY415 DESTINATION STATE(IF REQUIRED) <br />