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Please print or type <br /> UNIFORM FIAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> Nis[ WASTE MANIFEST <br /> 5.Generator's Name antl C A D 9 e 3 6 2. age 1 or 3.Emergency Response Phone 4.Manliest Tracking Number <br /> ;(Ol <br /> BOYS1yp�luAddress 62844 1 020;80597 JJK <br /> (BOO)4249300 <br /> MMQNQD`GTREGenerators Site Address(it different than mailing address) <br /> eras Phone: <br /> E.Transporter 1 Company Name 208 952-1222 N� 08037 4987 WEST LANE <br /> CA 95210 <br /> WORLD OIL ENVIRONMENTAL <br /> STOCKTON � <br /> SERVICES U S.EPA ID Number <br /> 7.Transporter 2 Company Name CAD 0 2 8 2 7 7 0 3 6 <br /> WORLDWIDE <br /> RECOVERY SYSTEMU.S.EPA ID Number <br /> 8,Designated FacilityNam INC. p <br /> e and Slte Address CAR 0 0 0 1 7 5 4 2 2 y <br /> YES MANAGEMENT,INC. U.S EPAID Number o <br /> Yu0US HIGHWAY 95 <br /> Facility's Phone: AZ 85365 <br /> AZR000521146 <br /> 9a. 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if an 10.Containers 11.Total U.Unit <br /> Y)) 13.Waste Codes <br /> No. Type Quantity Wt Not. <br /> 0 1 <br /> NON-RC No. <br /> WASTE,SOLID(PAPER FILTERS) <br /> 352 � <br /> U-1 2 D F— <br /> CD �s <br /> '<D <br /> 3. <br /> 4 <br /> 0 <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1.500.424-9300 WOES TERMINAL:CERES CS NAERG#9B1:171*PROFILE M 981: <br /> 161623NRS-PEP359 PAPER FILTERS * *APPROPRIATE PPE EQUIPMENT <br /> 15. ERA R" CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,are are d I am tpackaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and am rhe Primary <br /> Exporter,1 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ill am a small quantity generator)is true. Month Day Vear <br /> Ge r tors/Oflerof s Pnntedlryped Name Signa re f 0 <br /> rf.vis <br /> 16.International Shipments ❑Export from U.S. Port of entrylexit: <br /> ❑Import to U.S. \ Date leaving U.S <br /> Transporter signature(for exports only): <br /> 17.Transporter Acknowledgment of Receipt of Materials Montl1 Day Year <br /> Signature <br /> transport ntedfryped me <br /> Month Day Year <br /> / Sig tuts / y � �, <br /> ran dtryped Nam /i f C <br /> I.Discrepancy;' Residue PaAial Rejection <br /> ❑FutlRejection <br /> a.Discrepancy Indication Space F Quan <br /> r ❑Type ❑ <br /> Manifest Reference Number: U.S.EPAID Number <br /> Alternate Facility(or Generator) <br /> Month Day Year <br /> lity's Phone: <br /> Signature of Alternate Facility(or Generator) <br /> azardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 2. <br /> Il 1 Month Day Ye <br /> Signature �J ' <br /> Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 1 a <br /> ?signaled ty I <br /> i/Typed Name _ / l✓� u�, DESIGNATED FACILITYTO GENERA <br /> 8700-22(Rev. 12-17) Previous editions are obsolete. <br /> 711 UHWM 020380597JJK TSDF <br />