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Please printor type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1'Generator 0 0 4 r3 6 0 0 6 2 �9e 1 of 3.(800)cResponse <br /> 89300 one 4.Manifest Tracking Number <br /> WASTE MANIFEST 017 4 6 8 6 8 9 JJ K <br /> 5.GePA001IEAMMOM015"AR COMPANY Generator's Site Address(if different than mailing address) <br /> , <br /> 3190 AUTO CENTER CIRCLE <br /> STOCKTON Cis 95212. <br /> Generator's Phone: 916 928-4460 <br /> 6.Traq§gcttV1508ft-���ONMENTAL SERVICES U.SCEAAJp n927703-6 <br /> ng 2 7 7 0 3 6 <br /> VVC.) U.S.EPA IUD Number <br /> 7.Tra1L� �l� ce,OVERY SYSTEM INC. CAR 0 0 01 7 5 4 2 2 <br /> 8.NO Eaff We and Site Address U.S.EPA ID Number <br /> 2730 E 13TH ST <br /> YUNIA AZ 85365 A Z R 0 0 0 515f9 2 4 <br /> Facility's Phone: (928)344-9828 <br /> 9b.U.S.DOT Description(including Proper Shi m Name,Hazard Class,ID Number, 10.Containers 13.Waste Codes <br /> ga. p' (' gShipping 11.Total 12.Unit <br /> HM I and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> cc IKON-RCRA HAZARDOUS WASTE.SOLID(BRAKE LATHE:SHAVINGS) <br /> 0- god P <br /> o� �J <br /> Z 2. <br /> W <br /> C7 — <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL: NAERG#981:171 PROFILE#9B 601526 <br /> BRAKE SHAVINGS * *APPROPRIATE PPE EQUIPMENT" =9=ZD?0� 7 <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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 /> 7es/0fieroft Printedlfyped Name Syal Month Day Year <br /> 2 <br /> 116-Interriational Shi ents <br /> r-- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter ri ed/Typed ame Signature Month Day Year <br /> IL �- 101 <br /> T4 <br /> COO <br /> Transporter 2 Printed/Typed N m Signature Month Day Year* <br /> bbl 1 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpacePartial Re D Quantity ❑Type ❑Residue J El Full ReJectlon <br /> ❑ Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> v <br /> Facility's Phone: <br /> W 186.Signature of Alternate Facility(or Generator) Month Day' Year <br /> a <br /> z <br /> y 19.Hazardous Waste Report Management Method Codes(Le.,codes for ha ardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3• 4. <br /> . 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest ex as noted in Item 18a <br /> Pdntedrr,ypAd lvme - Signatur Month Day Year <br /> 4 r <br /> I lo 1:2�u o o2 I I Ito <br /> ( .�S <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESPGATED F CIL , O DESTINATION STATE(IF REQUIRE ) r` <br />