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Please print or type. Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator 1D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST .0 0 3.3 u 4.Z _ ,, •i_Y 020381778 JJ K <br /> 5,Generators Name and Maaing Address Generator's Site Address(if different than maikV address3 <br /> D AKOM L�eA TRACY CHEVROL€T-QAN001 <br /> PLATA WAY <br /> -- .'.A. D5304 <br /> Generators Phone: <br /> 5.TransWerer�1 Qompany Name U.S.EPA 10 Number <br /> OfOU t L.,.,1?JNMENTAL SERVICES C n L+ u ._3 2 7 7 0 3 6 <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDdtiIDE RECOVERYS7'STEM INC C A N U - K <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> n.iGHWAY 95 <br /> AZR000521146 <br /> Facility's Phone: ''q 744-??VS <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conta3mrs 11,Total 12,Unit I3.Waste Codes <br /> HM and f acking Group(if any)) No, Type Quantity WtIvol• <br /> 1.,~)N-RGRA HAZARDOUS WP3TE,SOLID(OILY SOLID) <br /> o <br /> LLI <br /> L 2 <br /> 3. <br /> A. <br /> 14,Special Handling Instructions and Additional Information <br /> r, EMERGENCY CONTACT CHEMTREC 1.800-4249300 WOES TERMINAL:CERES CS NAERG#gel-171 PROHLE;F t:L._ <br /> 162623QANCO1 OILY ABSORBENTS x - APPRr,7'� PPE EQWPMENTN. 4�ot,0 }� wa <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare ihatow aorUmvs 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'wnditim for transport according to applicable lntemational and national governmental regulat ons.If export shipment and I am the Primary <br /> Exporter.I oenify that the contents of this cortaigrwrent conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify Ihat the wasle minimization statement identified in 40 CFR 2132.27(ay(d I am a large quantity generator)or(b)(if I am a small quantity gertarator)Is true. <br /> GaneratoeslDff&rdrs Pnnledfryped Na7Signature 1 - Month Dal Year <br /> 1 t6.Intemational Shipments ice, <br /> H <br /> El Import to U.S. E—T hxgw from U.S. Port of entryiexit: <br /> 91 Transporter signature(for exports only): Date tearing U.S.: <br /> tx IT Transportar AcknovAedgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printedrryped Name ` Signature Moro Day Year <br /> a �11t��P b�vx, 1 � ! �h <br /> z Transpdrter2 PrintedlTyped Name � �- Y � + Signature � Month Day Year <br /> 18.Discrepancy <br /> 18a,Distxepancy Indication Space ❑ Quantity ❑Type Residue ❑Partial Rejection ❑Ful Reje6on <br /> Manifest Reference Number- <br /> 18b.Aternate Facility(or Generalor) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facsity(or Generatarl Month Dal Year <br /> z <br /> rU <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3 4. <br /> 20.Designated Facility Owner ar Operator.Certification of receipt of hazardous riptedals covered by the manifest except as noted In Item 1 Be <br /> Printecirrype Signature Month Day YeaUnr <br /> r <br /> EPA Form 8700-22(Rev-92-17J Pr vious editions are obsolete. 5 HATED LITY TO EPA's e-MANIFEST SYSTEM <br />