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a S It D a. <br /> r <br /> se print or type.(farm designed for use on-elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039, <br /> " <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1o 3.Emergency Response Phone, 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 3 5 0 (3 3 "1 I I Em. 421-= 0167045D622) J,1 K <br /> 5.169,611" <br /> 6 fab$1 INTilingAddress Generators Site Address(if different than mailing address) <br /> 38M RHONDA WAY <br /> TRACY CA C1a304 <br /> Generator's Phone: 2 0 9 2 2 9 - 7 4 4 0 <br /> 6.Transorter 1 Com an Name U.S.EPA ID Number <br /> �G`sOL1l`9 i\idl�®f�MJ( 4VTAL SERVrES INC CAR 0 0 0 1 7 1 0 1 7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDY', IDE RECOVERY SYSTEM) IKIC ICAROOO 1 7 5 4 2 2 <br /> 8.Resipo� d F,�d tarrband Site Address U.S.EPA ID Number <br /> 2730 E 13TH ST <br /> YUMA AZ3a-1e01 <br /> Facility's Phone: M -2M J.A Z R 0 0 .0 51 5 0 2 4 <br /> ga. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1-KQM-RCKA MZARDOUS WASTE,SOLI®(OILY DEBRIS, <br /> o A R13ENT) 400 223 <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 9)YES-151426-MY CaUS ERM171 <br /> / HAMI .»«TO MAGM TRARM AIM USE jam:Ea C62t=0 20gl7 ' <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name;and are classified;packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I ai�tha Primary . <br /> Exporter,I certify that the contents of this consignment•conforrn to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.' <br /> Generator'slOfferor's Printedrryped Name Signature Month Day Year <br /> 16.International Shipments <br /> El Import to U.S. ❑Export from .S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w17,Transporter Acknowledgment of Receipt of Materials <br /> Transported Printedrryped N Signature Month Day Yearco <br /> CL <br /> ZQ Transporter 2 Printedfrype me SigrtStrTre Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityType❑ yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> / Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u*S. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year. <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment;disposal,and recycling systems) <br /> LLJ 1. T2. 3. 4. <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 Name Signature : Month Day Year <br /> t. <br /> EPA form 8700-22(Rev.3-05TPrevious editions are obsolete. DESMNATE® FACILITY TO GENERATOR STATE(IIS REQUIRED) <br /> • - , 12555.1217 �• • ' •' <br /> „ <br />