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Farm Ammved. OMR Nn. 21150-00391 <br />EPA Form 870.0-22 (Rev, 3-05) Previous editions are obsolete. 1. � DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator 10 Number I2.Pagelof <br />- 3. Emergency Response Phone <br />4. Manifest Tracking Numberr <br />WASTE MANIFUST:. C A D H C 1 9 Cs 2.o, 4 <br />1 <br />(AO0) 4'22-93VO <br />�/ <br />�„ 6 1 r 3 JJ <br />U� <br />,�, <br />.. s <br />5. Gmerato(s Name and MallinyAddress Generames Site Address (if different (ban mailing address) <br />PEEP 20`0; 0711 <br />RRVIMONJON fid) s` mp 4987 WEST LABE <br />Generators Phone: 4'3 9 9 22 12 22 STXXTON <br />CA <br />95210 <br />6. Transporter 1 Company Name <br />U,S, EPA ID Number, <br />WORLD OIL ENV€!iONNAIENTAI_ K114ACES <br />CAC) 0 2 8 2 7 7 0 3 6 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />WORDi1 IDE'iEr0'JrRY SYSTEM, IN01 <br />GA R.Q{? 04 <br />7 5 2.2:...: <br />a Designated Facility NameanBSitepddress` -- -- <br />US. EPAID Number <br />131 4 *a <br />YUMA Al 86395 <br />_ _ <br />AXR 0 0 0 51 5 9 2 4 <br />Factilyzs Phone:(;d' Fes^-�'. r�`d' 6 <br />gy <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, - <br />10. Conelnamit. <br />Talal <br />12. Ural <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wwol. <br />13. Waste Codes <br />No. <br />Type <br />1. MOINLRUA PAZARD01.13 VMWEP SOLID (PAPrO rVEP;S) <br />352 <br />i5lki <br />P <br />2 <br />i <br />rz <br />0 <br />3, <br />i <br />4. <br />14, Special Handling Instructions andAddmonal Information <br />E6AERG7 ENbY CONTACT : GME&ITRIEC 1"600-424-93W 1AVOES T EWUNA : Qf a 4S' h PIROFfl.t <br /># 98 : 611623Nns PIEP369 <br />PA4 l TE A&PROP IATE PIK f QuIPMER'T <br />Cie.- <br />C <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 condflon for transport according to applicable international and national governmental <br />regulations. It export shipment <br />and I am the Primary <br />Exporter, I cer ify that the contents of this consignment wnfarm to the terms of the attached EPAAcknowledgmeni of Consent. <br />I cergly that the waste minimization statement identified in 40 CFR 262.27(a) (if l am a large quantity generator) or ge) (ifI am a small quantity generator) Is lime. <br />GeneralorslOfferofs Pdn(ed7l'yped Name Signature ,rr9 <br />Month Day Year <br />V 6! Z ((a v 1,114 r z. G` <br />=z. RZrs <br />a <br />16. In1emalional Shipments i l <br />❑import to U.S. ❑Export from U.S. Pod of eniiyfexll: <br />Transporter signature (for exports only): Date leaving U.S.: <br />our <br />17.TransporlerAcknowledgmentof RemiptofMaledals - - <br />;'� <br />Signalure1� j ' , <br />Tra7n/s'pp)C�B'erl PrinyledRyped,Name (�t <br />- Day Year <br />}' <br />*i (` f_y f_ -r (` <br />/Month. <br />N✓ <br />4'3. Ems`+P C'+'' <br />Trampo[%r 2 Pdnledflyped Name -- - Sign elb e <br />Month bay Year <br />18.Discrepancy - <br />/ <br />18a.DiscrepancyIndication Space ❑ Quanfily ❑Type - ❑Residue ., <br />❑ Padlal ftejeciion <br />❑Full Rejection <br />Manifest Reference Number. <br />18b.Allernale Facilky(or Generace-) <br />U.S. EPA ID Number <br />- <br />V <br />.w <br />.Facibly's Phone !,:::,.: - <br />w <br />18c, Signature of Alternate Facility(or Generator) <br />Month Day Year <br />Q <br />Z <br />0 <br />rn <br />19. Hazardous Waste Report Management Method Codes (W., codes for hazardous waste irealmenh dlfiposel, and recycling systems) <br />2.. 3... ,. .. <br />4. <br />- <br />20. Designated Facility Owner or Operator: Certiticallon of receipt of hazardous materials covered by the manifest exceptae noted In Ilam 18a <br />Pdniedfryped N'a�e - Signaturel <br />Month 'Day Year <br />y <br />_ <br />