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Please print or type. Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE'MANIFEST G A L 0 0 0 4 0 2 2 0 2 (SM)424-9300 1 62796949 JJK <br /> 5.Generators Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> INN OUT BUB- 1� <br /> 18240 5 HARLAN ROAD <br /> LAI HWJP CA 85330 <br /> Generators Phone: ZY4 85"800 <br /> B.Transporter 1 Company Name U S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> WORlDW}L?E RECOVERY SYSTEM INC CAR 0 0 017 5 4 2 2 <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> YUMA YES 2 WASTE TRANSFER STATION <br /> 6600=JTH IIS HIGHWAY 95 <br /> YUMA AZ 95365 AZR000521146 <br /> Facility's Phone- f92813449828 <br /> 9a, 9b U.S.DOT Description(including Proper Shipping Name Hazard Class,ID Number. 10 Containers 11 Total 12.Unit <br /> arrd Packing Group(d any)} 13 Waste Codes <br /> HM Na Type Quantity WtNal. <br /> Ix 1 XDN-RCRA HAZARIDOUS WASTE. SOLID(OILY SOLIDS) <br /> 0 <br /> DM <br /> z 2 <br /> LU <br /> t9 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> ZMERGENCY CONTACT CHEMTREC 1.800-424-9300 WOES TERMINAL CERES CS NARG#981 171 *PROFILE€I 981 <br /> 162B23NRSINNS03 OILY SOUDS/PADS * -APPROPRIATE RPE EQUIPMENT <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 cordilioon for transport according to applicable Intematienal and national governmental regulations If export shipment and I am the Pnmary <br /> Exporter,)certify drat the contents of this consignment conform to the terms of the attached EPA AcknoWedgment of Consent <br /> certify that the waste minimization statement dentified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(di am a small quantity generator)is true <br /> Generators/Offerors Printe0yped Name Signature / Month Day Year <br /> j 16.International Shipments' ❑Im to u.5 rr <br /> port t Export hon U S Port b[enlrylw'Jt: <br /> Transporter signature(for exports only) Date leaving U1.6,: <br /> W 17 Transporter Acknowledgment of Receipt of Materials <br /> I-- Transporter 1 Prinled/Typed Name Signature Month Day Year <br /> z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ auandty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> U <br /> Facibys Phone <br /> w 18c.Signature of Alternate Facility(or Generator) r Month Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal and recycling systems) <br /> G 1. 2 3. 4, <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest ekcepl as acted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 870022(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />