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MiLiase print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2-Page 1 of 3.Emergency Response Phone 4.Mandest Tracking Number <br /> WASTE MANIFEST Y L 0 0 u 3 6 8 6 9 3 (800)424-9300 1 O 0 3 2 (7 <br /> JJ K <br /> 5-Generators Name and Mailing Address Generators Site Aftess(if different than mailing address) <br /> imFLR,,TRUCr, .;. SH AND REPAIR JAZZ GROUP <br /> 2142 W.YOSEMITE AVE. JAZZ GROUP INC <br /> MANTECA CA 95337 <br /> Generator's Phone: 209 239-8111 <br /> 6.Transporter 1 Company Name U.S.EPA Id Number <br /> ,;':JRLD );L ENVIRONMENTAL SERVICES i A D 0 2 8 2 7 7 0 3 6 <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC. CAR 0 0 01 7 5 4 2 2 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> fES MANAGEMENT. INC. <br /> 6500 UIS HIGHWAY 95 <br /> YUMA 85365 AZR000521146 <br /> Facility's Phone. ❑ . <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 12-Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity Wt.IVot. <br /> a NON-RCRA HA AR03US WASTE.SOLID(PAPER FILTERSy �- <br /> 0 <br /> W <br /> � a <br /> M 2. <br /> L <br /> 3. <br /> i <br /> i <br /> i <br /> I i <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS NAERG#961 171 'PROFILE#SISI <br /> 162623NRSIMP072 PAPER FILTERS i q <br /> PP- EQUIPMENT <br /> 15- GENERATQR'SIRFFEROR'S CERTIFICATION: hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping rtwlC and areeccfassifled,packaged, <br /> marked and labeledlptacarded,and are in all respects In proper condition for transport according to applicable,International and national govemmental regulations.If exporl shipment and I am the Primary <br /> Exporter,I ooOfy that the contents of this consignment conform to the terms of the aaad*d EPAAcknowledgment of Consent. <br /> I certify that the waste minimization stalement identified in 40 CFR 262.27(a)(if f am a large quantity generator)or(b)(Ht am a small quantity generator)is true. <br /> Generatorsferar's PrintedlTyped Name signature Month Day Year <br /> � 1/ -4 Z <br /> —9 16.International Shipments <br /> Import to V.S. ❑Export from U.S. Port of entrylatt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> rr <br /> Y! 17.Transporie Ackno ledgment of Receipt of Materials <br /> Transporter 1 PtintedlTyped Name Signet u Month Da Year <br /> M I'C �Q t <br /> 2 Transport Name Sign to Montlr Day Year <br /> a ` <br /> 1 .discrepancy <br /> 18a.Discr Indicat on Space Quantity y ❑Full R <br /> ❑T pe Residu Partial Rejection ejectbn <br /> Manifest Reference Number; <br /> 18b,Atternate Facility(or Generator) U.S.EPA 1D Number <br /> U <br /> tai Facility's Fhone: <br /> w 180-Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> N19-Hazardous Waste Report Management Method Codes(te.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3. 4- <br /> L <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 180- <br /> PrintedlTyped Name Signe Month Day Year <br /> LC-L <br /> EPA Form 870D-72(Rev.3-05) Previous editions are o solete. D 61N TE F8CILITY TO DESTINATION STATE(IF REQUIRED) <br />