COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Please print or type.(Forn designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL 0 0 0 4 0 0 1 6 7 1 (800)424-9300 018530185 JJ K 5.Generators Name and Marling Address Generator's Site Address(If different than mailing address) SPEEDEE OIL CHANGE&TUNE UP-GRANTLINE RD 245 W. LOUISE AVE MANTECA CA 95336 711 W. GRANTLINE RD Generators Phone: 209 836.1557 TRACY CA 95376 6.Transporter 1 Company Name U.S.EPA ID Number WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 7.Transporter 2 Company Name U.S.EPA ID Number WORLDWIDE RECOVERY SYSTEM INC. CAR 0 0 0 1 7 5 4 2 2 8.Designated Facility Name and Site Address U.S.EPA ID Number YES MANAGEMENT. INC. 6500 US HIGHWAY 95 YUMA AZ 85365 AZR000521146 Facilityrs Phone: 197A)344-9828 go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codes HM and Packing Group(f any)) No, Type Quantity WWoI. a 1.NON-RCRA HAZARDOUS WASTE SOLIDS(PAPER FILTERS) / 352 _ D M P z z. w c7 3. 4. 14.Special Handling Instructions and Additional Information EMERGENCY CONTACT :CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS *PROFILE#981: 162623NRSSPE099 PAPER FILTERS OP I T P E EQUIPMENT/ 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the props shipping name,and are classified,packaged, marked an.4jabeVplacarded,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 E, ody,Tcertify th t the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Conse Icefth that the minimization statement identified to 40 CFR 28227(a)(if I am a large quantity generator)or(b . em a I quantity ge )Is true. tGenerat rslOfte rs P on ted/T Signature Month Day Year InEl Import to U.S. Export from U.S. P of entrylexit: Z Transporter signature(tor exports only): Date leaving U,S.: 17.Transporter Acknowledgment of Receipt of Materials T rt er 1 PrintedlTyped Name Signature Month Day Year F 1001// Transparte Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Ll Quant ty ❑Type ❑Residue ❑Partial Rejection El Fell Refection Manifest Reference Number. 18b.Alternate Facility(or Generator) U,S,EPA ID Number J U Facilityrs Phone: Month Day Year LU 18c.Signature of Altemate Facility(or Generator) a Z VS19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2 3, 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In pqm 18a Printed/Typed 04ne Signature Month Day 7-7FK 1 C-4 A V0 A '61- - I 1 19 11'2--1 EPA Form 870 22(Rev.3-05) Previous editions are obsolete. DESIGNATEd FA ILII DESTINATION STATE(IF REQUIRED)