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LTSr GAS* 9 . 2044• <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS ll.QeneratoriONumbef 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 018 2 6 4 5 1 (800)424-9300 018 2 3 2 6 2 9 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(A different than mailing address) <br /> JIFFY LUBE 02322 k <br /> 500 E.KEITLEMAN RD. <br /> LODI CA 95240 <br /> Generators Phone: 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 /> BAKERSFIELD TRANSFER. INC ~ <br /> 1620 E. BRUNDAGE LANE <br /> ERSFIELD CA 93307 CAL 0 0 0 2 8 2 5 9 8 <br /> Facilitys one: <br /> 9a 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codas <br /> c 1 NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER) .4+ qb p 223 <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424.9300 WOES TERMINAL DIXON NAERG# 9B1: j jP� Fll�i 01LY <br /> WATER *EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 *ADDITIONAL EPA CODES:9131OPRIATE <br /> PERSONAL PROTECTIVE EQUIPMENT Q'•S r',(/ <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 labeled/placarded,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 EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'sl0fterofs Printed/T ped Name Signature Month Day Year <br /> u0mtka, vak' - ,-- <br /> J 16,Intemalional Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedfryped Name / Signature Month Day Year <br /> a Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partal Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 1181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> LL Facilitys Phone: - <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> c 1. 2. 3. 4. <br /> 20.Designated Fadlity,Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as naled in Item 18a <br /> r nted(ryped Name Signature Month Day Year <br /> PA Form B700-22(Rev.3-05)/Previous editions are obsol e. rew4IGNATED,,,F,9CILITY TO DESTINATION STATE(IF REQUIRED). <br /> 12865.2024 1 <br />