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11111��I�11lIIIIIIIIII'IIII�IP�IIi <br /> 1Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ll�lll�ll�l�llll� <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.—Manifest Tracking Number <br /> 1N'A EMANIFEST CAL000388158 1 8775'i72E6t2 011385160 FLE <br /> 5.Generators Name and Mailing Address <br /> Generators Site Address(if different than mailing address) <br /> F'etcD #1319 Petco#1319 <br /> 2094787726 5406 Pacific Avenue <br /> Stockton X406 Pacific Avtrtuc <br /> GeneiatorsPhorie: I CA 95c07 Stockton <br /> 6.Transporter 1 Company ame , CA 95207. <br /> Stel-icycle Sipecialty Waste Solutions lnr- U.S.EPA ID Number <br /> 7.Transporter2Company Name MNS0001 i 0924 <br /> Worldwide Recovery Systems U.S.EPAIDNumber <br /> 8.Designated Facility Name and Site Address yUMa e c CA R000175422 <br /> 273 + E. 13th Street U.S.EPA ID Namber <br /> Yuma, AZ 85365 <br /> Facility's Phone: 9286428938 <br /> AZ R000515924 <br /> ga. 9b.U.S.D07 Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11,Total 12.Unit <br /> No. Type Quantity Wtivol. 13.Waste Codes <br /> W 1Qa1, azar or-t� waste, iquid (Sur actant, c DF 0 195 331 <br /> w <br /> z 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1, 103591 (Non—Ha z Liquid 5) <br /> 5. TORSI FEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above b 6 oper shipping name,and are Classified,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable iniomati national govemm tat gufations.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 EPAAcknowledgment of ansae <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator nt d I se small quantity nor /� <br /> Gen rato (erors nt ype ame ) ) q ty for)is true. <br /> Igoe ure I n t? a 'O <br /> "`tet on ay ear <br /> 1 16.Intemational Shipmen 1111 , i t;.. 2v7I <br /> z ❑Import to U.S. ❑Export from U.S. Port of enlrylexik <br /> Trans otter si nature for ex orts on! <br /> LU <br /> 17.TransporterAcicnowledgment of Receipt of Materials Date to U.S. <br /> Transporter 1 Printeciffyped Name <br /> p g ature <br /> rL y ac__. Mon17 ay ear <br /> T porter 2 PrintedfT me I qn re .:.1 16 X01 - <br /> ont Day <br /> 18.Discrepancy , <br /> 18a,Discrepa Indication Space <br /> ❑ Quantity ❑Type Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator} Manliest Reference Number: <br /> U <br /> U.S.EPA ID Number <br /> 4 <br /> 0 Facilil's Phone: <br /> 18c.Signature of Attemate Facility(or Generator) <br /> Monfh Day Year <br /> LU 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2. <br /> 3. 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest ex <br /> ,;dlTypad as noted in Item 18a <br /> —.- N e <br /> ' k Signature <br /> _ Month Day Year <br /> EPA Form 8700-22{Rev.3-05) Previous editions are obsolete. J 1 <br /> DESIGN!T FAC ITY TO DESTINATION STATE(IF REQUIRED) <br />