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Please print or".(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.205MO39 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST .6 617695179 JA <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> IMPERIAL TRUCK WAS AND REPAIR,JAll GROUP <br /> 21.42 W-YOSEMITE AVE JAll GROUP INC <br /> MANITECA CA 95337 <br /> Generators Phone: ?69?3 $311 <br /> 6-Transporter 1 Company Name U-S,EPA ID Number <br /> '40 RtC 0 1 L EfJYlRONMENTAL SERVICES C A 0 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDiNJDE RECOVERY SYSTEM INC. C A.8 0 0 0 1 7 5 4 2 2 <br /> 8-Designated f=acility Name and Site Address U.S.EPA ID Number <br /> YE:i [virkitAGEiviEti1. 1r4c <br /> 6500 US HIGHWAY 95 <br /> YUMA A ' 85 CO-- AZR000521146 <br /> Facilitys Phone: ,r-.11- -r- <br /> ga. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total t2.Unit 11 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity N AU, <br /> a 1'NON-RCRA HAZARDOUS WASTE.SOLID(PAPER FILTERS) I <br /> D M i - <br /> w <br /> LU <br /> 3. <br /> I <br /> f <br /> 4. <br /> 14,Special Handling Insbuctions and Additional Information <br /> EMERGENCY CONTACT :CHEMTREC 1-800-424-9300 WOES TERMINAL: CERES CS NAERG#961. 171 *PROFILE#9131 . <br /> 162623N?SINIP072 PAPER FILTERS * *APPROPRIATE PPE EQUIPMENT. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurst*described above by the proper shipping name,and are classified.packaged, <br /> marked and tabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmefital regulations.If export shipment and I am the Primary <br /> Exporter.I oertify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(a I am a large quantity generator)or(b)(i€I am a small quantity generator)is true. <br /> Generator Offeror's PrintedrTyped Name Signature Month Day Year <br /> /z 3/ <br /> j 16-Intamational Shipments <br /> F— Import to U-S- ❑Export from U.S. Port of entrylexit <br /> Transporter signature(for exports only),. Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Tran rter 1 PrintedlTyped Name Signalu Month Day Year <br /> ` Z � . / <br /> Z ransporte[2 Printed )ped NameSignature - Month Day Year <br /> 101, <br /> � r y <br /> p 18-Discrepancy <br /> f¢ 18a.Discrepa.9cy Indication Space <br /> ❑ Quantity ❑Type Ll Residue Ll Partial Rejector Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> 18c-Signature of Alternate Facility(or Generator) Month Day Year <br /> s � <br /> rn <br /> 19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment.disposal,and recycling systems) <br /> C 1. r 2. 3. 4, <br /> V <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped a e Signature Month Day Year <br /> jn W,\ 0-k 1'4 INt <br /> r �l <br /> TO DESTINATION STATE{IF REOUI <br /> EPA Farm 870G-22(Rev.3-05) Previous editions are obsolete. D�$I A7E� F IL <br />