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L -0 OD N <br /> CIO t O0 N N <br /> O FD p C <br /> O <br /> Z DD (JI N <br /> T-F ReaSs prim or type. .. O . <br /> Form A roved pM$Ku.2U5p-0U39 <br /> UNfFORiH HAZARDOUS i GB"0f8�ID Nurnhar g.p i of 3.Eme[a Res e C <br /> D ape p my pnnge Phone Maneast xre�Ylr N*mh.r <br /> FC WASTE MANIFEST CAL 0 0 0 3 6 8 9 9 3 1 (8)D)4249300 0 2 0 �J 6 7 3 J3K � ° <br /> D sE S Ganeata sNamaarM`Ma_bgAddress Ell <br /> p <br /> IMPERIAL TN{/GR WASH AND REPAIR�YlZ2 GROUP Generators Site peeress lit diff®rem than mailing address) � <br /> W YOSEMITE AVE JAZZ GROUP INC 3 <br /> M MANTEL, CA 95397 <br /> Generators Phone; Z(19 239.8111 � D <br /> He.Transportar t Cemparry Name U 5 EPA ID Number N <br /> a WORLD OIL ENI/IRONMENTAL SERVICES <br /> P GApF32827703C+ <br /> E Tran mp 0- <br /> T WORGDWIta RECOVERY SYSTEM INC. u 5 EPA to Number ! � <br /> 0 <br /> CAROpp1T5422 to <br /> 6 Hated FadHly Mame and SAe Address <br /> 5 MAMAGEIkE/PT INC, U.S.EPA 4D Number <br /> &800 U8 HIGHWAY 95Ln <br /> If YUMA AZ SIG,at. It <br /> Fadfiry's phone- (948 9828 A Z R O 0 0 6 2 1 1 4 6 N <br /> ga_ 9b.U.S.DOT DesCriptlen(including Proper Shipping Name.Hazard Class.10 Number, 10.Containers 11,TOI31 12.Unit <br /> [ HM and Packing Group fit any)) No. Type Ouantity WI.NoI. 13.Waste Codes <br /> 1NOfRACRA NVARDOUS WASTE.SOLID(PAPER F)LTFRSI rp <br /> 352 <br /> _r <br /> w P O <br /> N <br /> w O <br /> C7 W <br /> 00 <br /> O <br /> 3 v <br /> W <br /> S <br /> a O <br /> tT <br /> LA <br /> fD <br /> 74 Special HantlhnglnsLru=nsandAddGooallnfermation rD <br /> Q <br /> EMERGENCY CONTACT'CHEMTREC 1,SW424-9300 WOES i I:.HtMINAL:CEi,L-. a NAERGO SIBS:171 `PROFILE R 9f39. <br /> 162623NMAIP072 PAPER FILTERS* *APPROPRATE PPE EQUiPMEN 4—c�, <br /> 'i <br /> 15 SENERATOR'S/OFFEROR'S CER77FtCATION:i hereby declare that the contents of Ibis consignment are fug and accuralel described above b the o et sht p <br /> mocked and fabaledVacarded,and are in ail res cls g Y Y y pr p Aping name.artl are Ga55iGed,packaged. rt <br /> pe m proper condition for transport attached <br /> according toknowl dg internal of tionsent national governmental regulations.II export sMpment and Y am the Primary <br /> Exporter 1 rxrtrfy that the contents of this wnsignmenl conform to the terms of!de attached EPA Acknowledgment of Consent. 0) <br /> 1 o"fy Mal bre was le mtnrmipation statement identiFed in 40 CFR 262 27(a)(if I am a large quantity generator}or(b)lit V am a small quantity generator)is true- Q <br /> C—raforyOrleror's Pprtted:7yped Name Signature Month Day, Meas!' (Li1 <br /> 16 Interna6tmal Shlpments 7 <br /> FJ Import Import to U. <br /> ❑Export from U.S. Port of elr* <br /> forWtransporter signature IF— <br /> JX <br /> f?TransporterAdrrtolWedgment of Receipt of Materials Date leaving US <br /> n <br /> Transpor erg PrintedRyped Name <br /> p Signature Month Day Y <br /> a er Transpo 2 Pnntedlryp¢d Name Signature Month Day} Y' <br /> .'o Discrepancy <br /> 180.Discrepancy Indication Space <br /> ❑ Ouantity ❑Type ❑Residue ❑iPerlial Rejecdon ❑Full Rejection <br /> Man fest Reference Numhar <br /> 19b-FUlernatg Facility is <br /> Ge <br /> 18b <br /> EPAfO IVttnl6et <br /> J <br /> U <br /> LL Facdtt)"S Ptlorte <br /> O 1 go Stgnature of A lemale Fal for Gerlerav,f i<1olt@i 01M <br /> VIM <br /> 4 p n <br /> Q O <br /> 9 19 Hazardo s til ReW Management Method Codes It e.,codes for hazardous waste treatment,disposal,and nil systems] M Q <br /> J 1 2 3 L <br /> Facility patter rx Operator Gerlifi on of ri 1pl of hazardous coasted rdous metaby the rwifeal exoW ss nod in Wn IBM. <br /> 20.pest Haled �] <br /> Mill <br /> O <br /> FinntedlTyP� <br /> tQ -t <br /> m pheyiouls edibons are obN <br /> Form 8700-22(Rev,12-17) <br /> solete rn <br /> p r n . <br /> w <br /> 0 <br />