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G .:.. <br />,V t <br />PIPacP nrint nr fvna_ <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. UtNtRA I G3td' IiNI i IAD, UUF Y <br />UNIFORM HAZARDOUS <br />1 • Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone� <br />:1 <br />4. Manifest Tracking Number <br />5 <br />WASTE MANIFEST <br />to A L 00 0 46 %% 0 1. <br />l <br />(W-4))) 424--9:M <br />5, Gonerators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />I LACY CHRYSLER R,OIX,f JCEP RAM <br />8460 NAGLI':- )°t=_`7 <br />E r'AcY VP, <br />Generator's Phone: 209 82048 00 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />WORLD OIL VVIVI i NIVIE:NTAL SERViGES i A D 0 2 8 2 l Y 0 3 6 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Sita Address U.S. EPA ID Number <br />WORLD Olt. REECYCLING <br />2WO N, MAMMA -STREET <br />(MAKON CA X0222 CATOBOO i;3362 <br />Facility's Phone: 310 631-71.00 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Centelners <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />quantity <br />W1.Nol. <br />ON -V RA 11MARDO r WNW P, HQUID (BETAKE FUJIM) <br />22,3 <br />Z <br />2. <br />W <br />U <br />3, <br />4. <br />14. Special Handling Instructions and Additional Information <br />FAM.RGM(N CONTACT : GHEVIi`REG t•SW-424.9300 WOESTERMINAL: CERES CSS NA RGN 9BI o 171 't PROFILE R RF.) <br />479-324 BRAKE FLUID APPROPRiATF PPE F -QUIP ENT <br />15, GENERATOR'S10FFEROR'S CERTIFICATION: 1 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. lnternalionaland national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAArrlmowledgment of Consent. <br />'I ceitify 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 />GeneratoeY0ffjror'sPnnted/Typ� Name Signature Month Day Year <br />'{ <br />16.`International Shipments <br />❑ Import to U.S• .N;a:❑ Export from U'S. 1 Port o€entryfezitt <br />Transporter signature (for exports only): Date leaving U,S.: <br />W <br />17. Transporter Acknowledgment ofReceiptofMateriais <br />Transporter 1 Pnntedfryped Name SignatureMonth Day Year <br />0. <br />Z <br />Transporter 2 Printedlfyped Name Sig'alare Month bay Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ ooantityyp <br />❑ Type .,.5 ❑Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />r <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />0 <br />rat. <br />Facility's Phone: <br />W <br />18c. Signature ofAllemate Facility (or Generator) <br />Man1h Day Year <br />Q <br />Z <br />E19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />1. <br />2. <br />L <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a 1, <br />PrintediTyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. UtNtRA I G3td' IiNI i IAD, UUF Y <br />