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lease print or type.(Form 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.Manffest Track' Number WASTE MANIFEST CAD 982 061 079 1 i 916-849-0144 0160 7868 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Cox Bros Tire Service 507 E. 11th St. Tracy, C A 95376 Generator's Phone: 209-835-0880 6.Transporter 1 Company Name U.S.EPA ID Number SACRAMENTO WASTE OIL CAL 913 534 912 7.Transporter 2 Company Name U.S.EPA ID Number Worldwide Recovery Systems, Inc. CAR 000 175 422 8.Designated Facility Name and Site Address U.S.EPA ID Number Yuma Yes 2 Waste Transfer Facility 6500 US Highway 95, Yuma, AZ 85365 Facility's Phone: 928-344-9828 A Z R 000 521 146 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(f any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. v 0 NON-RCRA HAZARDOUS WASTE SOLIDS o� I DM 2vo p (Oily Absorbent) 352 W z 2. L c� 3. 4. 14.Special Handling Instructions and Additional Information HANDLERS TO BE TRAINED AND USE PPE 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, 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 am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAclmowledgment of Consent. I certify that the waste minimization statement id ntified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)i true. Generator's/Offeror's Pdnted/Typed Name ) Signature Month Day Year ��• j t. �j rc- I'k ')r. International Shipments ❑Import to U.s. El p ry _ Export from U.S. Port of ent lexit: z Transporter signature(for exports only): Date leaving U.S.: L 17.Transporter Acknowledgment of Receipt of Materials Y Transporter 1 Pdntedrryped Name Signature Month Day Year i Albert M. .:er-ns-7iaaz " 22 QTransporter 2 Printed/Typed Name + Signature Month Day Year YVIA 1 T7 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑TypeEl j j Residue Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ i Facility's Phone: Llr 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z n 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) j1. �I 2. 3. 4 20.Designated Facili Own r Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name - Signature Mon Day Year PA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNAT FACILITY TO DESTINATION STATE(IF REQUIRED)