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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 4 0 7 0 3 0 1 (800)424-9300 026904942 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> UNITED#5447 <br /> 1301 ACADEMY CT <br /> FT COLLINS AZ 85024 1469 E HAMMER L <br /> Generator's Phone: 916 991-1100 STOCKTON CA 95210 <br /> 6.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 /> 8.Designated Facility.Name and Site Address U.S.EPA ID Number <br /> WORLD OIL RECYCLING <br /> 2000 N.ALAMEDA STREET <br /> COMPTON CA 90222 CAT 0 8 0 0 13 3 5 2 <br /> Facility's Phone: (310)537-7100 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1RQ, UN1993,WASTE FLAMMABLE LIQUID, N.O.S.,(TEST WATER),3, D001 D018 43 <br /> o PGII , DM 10 G <br /> z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS NAERG#9131:128*PROFILE#9131: <br /> UN11002-030725 TEST WATER * *APPROPRIATE PPE EQUIPMENT X aON <br /> 55 do <br /> 15. GENERATOR'S/OFFEROWS 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 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify,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 /> Generator's eror's PdntedfTyped Name Signature Month Day Year <br /> cJ <br /> ,j 16.Intematio a S ipmen <br /> I- ❑Import to U.S. ❑Export from U.S. Part of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> a2 Transporte 1 Printed/Typed Name /,�,, Signature Month D a Year <br /> a k' 1 l/�K P1 . <br /> �5 Z nsporter Printecirryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LA- Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. <br /> De ignated Facility Owner or O erat r.qertificatonof receipt of hazardous materia coven the manifest exce as nde in Item 1 <br /> npejD1&W( � Signature <br /> \ttf <br /> -22(Rev.12-17) revious di6 ns are obs ate. ATED FA I EPA's e-MANIFEST SYSTEM <br />