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Please Mint or w;a. (Form designed for use on elite (12-pildt) lypeu tr.) <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete <br />DESIGNATED FACILITY TO r <br />UNIFORM HAZARDOUS <br />11. Generator ID Number <br />i51'o� <br />2. Pape 1 or <br />1 1916-371-5747 <br />3. Emergency Respoom Plane <br />4. <br />016-(81031 JJK <br />WASTEMANFEST <br />5 Generator's Name and Mahg Address , Gen&-Aes Site Address (if different than maftaddtess) <br />z 3� Z3 S. Surd Rd 7K&cy td ceS 3�y <br />-7-5 <br />/� — Occ, <br />Generator's Pkm: <br />6. Transporter 1 Company Name U S. EPA ID Number <br />SACRAMENTO WASTE OIL CAL 913 534 912 <br />7. Transporter 2 Comparry Name U.S. EPA ID Number <br />Worldwide Recovery Systems CAR 000 (175 422 <br />8, Designated Facility Name rod Addtese U.S EPA ID Number <br />Yuma Environmental Services, Inc. <br />2730 East 13th Street Yuae Arizona,,86365A <br />Fed3ys Phone: 428-642-8938 AZR 000 515 924 <br />9a <br />9b, U.S. DOT Description (including Proper Stilppkig Name, Hazard Class ID Number.. <br />10 Catchers <br />11 Tata) <br />12 Unh <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Parking Group Of any)) <br />O. -My <br />W Wil <br />o <br />.` <br />'NON-RCRA HAZAR US WASTE OLIDS <br />0 <br />D <br />Q <br />557- <br />_ <br />Daiof.� <br />z <br />W <br />2 <br />3 <br />4 <br />14. ktstrttctbro &id AddYiptal IMomtatlon <br />HAIL LERS BE T�AINED AND USE PPE <br />ERG # 128 <br />15. GENERATORTdOFFEROR'S CERTIFICATION: 1 hereby declare tut tie contends of this con irmad ere hilly and accurately desaibed above by the proper shipping tame, and are classified, padm9W. <br />madced and Iabel"placanied, and are In al respects In props condition for transport according to applicable intematlorW and national governmental regulations. If export ditprnent and I am the Primary <br />Exporter, I certify that IN contents of this consignment conform to tie terms of tie adad*d EPAAd=r44m9rri of Consent. <br />I certify Thal the waste meson slatement Idertified in 40 CFR 262.27(a) (if I am a larpe quantity generator) or (b) (t! a amag quaritily generator) is true. <br />Gennsato &'-Awws Pntntedifyped Name Signature - Month Day fair <br />ig �a�i <br />yG <br />—r <br />16. Intematioa Shipments <br />❑ import W U.S. ❑ Expwl from US, Port of etitiyletdC <br />Transporter signature (for exports oNy): Date bating U.S.: <br />a <br />17. Transporter Admvaledgment of Reraipt of MaWiabl <br />Trar>sgorter i PrWl.Tr Nang r Day Year <br />//'j,� rrJfV11 f <br />Transporter 2 Pr4dedrTyped Name Month Day Year <br />te- , <br />�.rr. sisq✓�' r <br />18. Disaepancy .��"''�"' <br />18a. Diurepancy Indication Space ❑ W." [:]TypeElResidue ❑Partial Refectlon ❑ Fvll Rejectbn <br />Manifest Reference Number. <br />18b. Alternate Faolity (or Generator) US EPA'D Number <br />C <br />U <br />LL <br />Facilitys Phone <br />0 <br />18c. Signature of Cremate Facility 'or Generator) <br />Month Day you <br />Q <br />Z <br />19. hazardous Wada Report Management Meftd Codes 0.e codes far haza+daes waste treatment deposal, and recycling systems} <br />G7 <br />1 <br />2 <br />3. <br />4 <br />20. Designated Facility Owner or Operaur Certification of mcalpt of N uardous materials covered by the manifest except as nded In Item 16a <br />Flin-. Typed Name afore _ <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete <br />DESIGNATED FACILITY TO r <br />