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Please print or type.(Form dost ed for use on elite 124tch typewrites) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ntwildst Traddng Rum <br /> WASTE MANIFEST CAL 0 0 0 4 31914 1 (800)4249300 018530493 JJ K <br /> 5.Generator's Name and IMa6in Address Genemtofs SEteAddmss(11 different than mallIng address) <br /> JIFFY LUSE#38 8 <br /> 1471 SHORE ST <br /> WEST SACRAMENTO CA 95691 3276 GRANT LINE RD <br /> Generator's Phone: 208 229-7915 TRACY CA 95304 <br /> 6.T 1 Name U.S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES C A 0 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Com n Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC. CAR 0 0 017 5 4 2 2 <br /> 8.Designated FaclI�y Name and Site Address U.S.EPA ID Number <br /> YES MANAGEMENT, INC. <br /> 6500 US HIGHWAY 95 <br /> YUMA AZ 85365 A Z R 0 0 0 5 2 114 6 <br /> Fadi s Phone (928A44-9828 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Urd 13.Wasta Codes <br /> HM and Paclft Gragr(Tarry)) No. Type Quantity Wtivol. <br /> 1 NON-RCRA HAZARDOUS-WASTE.SOLID(PAPER FILTERS) 352 <br /> 0 <br /> .� <br /> DM P <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800.4249300 WOES TERMINAL CERES CS;NAERG#9131:171 *PROFILE#981: <br /> 1626 3NRSJIF761 PAPER FILTERS * *APPROPRIATE PPE EQUIPMENT <br /> ��'�fa � 2429 ZXs <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oons%n ment are fully and accurately described above by the proper shipping name,and are dassM,packaged, <br /> marked and tabeledlplacarded,and are In all respects.in proper condition for transport according to applicable Intemational 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 EPAAckrwwledgment of Consent. <br /> ce"that the waste minimization stateme entified In 40 CFR 262.27(a)(N I am a large quantity generator)or(b)(If I arfig6nall quantity generator)Is true. <br /> Generetor s1ORerors Prin N Signature Month Day Year <br /> /��, c 9 <br /> F p ❑Import to U.S. ❑Export from U.S. Port of emrylexix <br /> Transporter signature(for exports only): Date U.S.: <br /> 17.TransporterArlmawledgment of Receipt of Materials <br /> aTranspo n ame Signature Months Day( Year <br /> os.. vyl IL <br /> 09 1 19 <br /> CTransporter 2Pdntedlfyped 8 Signa Mo(1��`nth � Y r <br /> 0. <br /> 18.Discrepancy 401 <br /> 18a.Discrepancy In fication Space ❑ Q.'Uty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Aftemats Facility(or Generator) U.S,EPA ID Number <br /> Ci <br /> u`t. Faalitys Phone: <br /> w 18c.Signature ofAttemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes p.a.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> 1. +fi 2. 3. 4. <br /> 20.Destgnated Fadil r or Operator.Cert utkm of reoelpt of hazardous materials covered by the manifest except as noted In Item 1 <br /> Prin nature Day YW <br /> AV ov <br /> (A-0CA"k <br /> EPA Form 8700-22(Rev.305) Previous editions are obsolete. DESIGNATED FA LITY TO D INATION STATE(IF REQUIRED) <br />