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Please print or type. (Form des -aped for use on elite 112 -Ditch) %mewriter ) <br />FmmAnnmv l OMR NJ 7runrnzo <br />EPA Farm 870D-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />I'Mrator'll4lilugth <br />2 Page 1 of <br />1 <br />3. Emergency Response Phone <br />X110,---a7 <br />4. Mest rac <br />a19O31 <br />WASTE MANIFEST <br />JJK <br />5. Gererata's Name and M -:-ling Address Generators Site Address (d different than mailing address) <br />It tl �[� C. G:lr";,'�i:.>- `i f.:.-. <br />„.)�)'ft•l,� <br />r i`�'% <br />Peneralors <br />6. TransR?dw 1 Meme U.S EPA ID Number <br />SAURAt'iEt WASTE OIL CAL 913 534 912 <br />7. Transporler 2 Cornpatty Name U.S. EPA ID Number <br />Worldwide Re,.ovorg Systems >' 000 075 422 <br />8. rutted ty Name and Site Aa U.S. EPA ID Num1w <br />tLz2Fi vzro=entaiServices, Inc. <br />2730 East 13th Street Yuma Arizona 56365A <br />928-642-8938 AZR OW 515 924 <br />Facility's Phone: <br />ga. <br />gb. U.S DOT Description (ndudng Proper Shipping Name, Hazard Ctass, ID Number, <br />10 Containers <br />11. Total <br />12. Uoll <br />13. Waste Codes <br />No <br />Type <br />HM <br />and PiGroup an <br />Fading p y)) <br />Quantity <br />WILAK <br />Dd <br />1 NON-RCRA HAZARDOUS WASTE SOLIDS <br />-- <br />Z <br />W <br />2. <br />3. <br />4. <br />14t=Mln on notKA I AddifionalInformationN-,' D USE PPE <br />12, <br />15, GENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of this axnsgnmenl are filly and accurately described above by the proper stnippinng name, ard are dass1w. packaged, <br />marked and labeled/placarded. and are in all respects In proper condition for transport according to applicable International and national govemmenlal regulations H export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the temss of the attached EPA AdmowleNmwt of Consent <br />I certify thio the waste minimization statement ldentiked in 40 CFR 26227(a) (h I am a large quantity generator) or (b) (Ijim a stroll quantity generator) is true <br />GeneratorslO OM6 PdntedfTyped Name Signature �/ Month Day Year <br />—+ <br />16. knemaaoral Shipments ❑Import to U.S. ❑ Export horn U.S - Port of entrylexit <br />Transporter signature (far exports only): Date leaving U.S.: <br />rY <br />17. TrarnporlerA*vMedgment of Receipt of Materials <br />`' <br />Trarspo PdrdedRyped Name S"A4grtth Day Yew <br />—n <br />ZTransporter <br />2 PnntedlTyped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Atlemats Facility (or Generator) US EPA ID Number <br />a <br />U <br />tai <br />Facktyrs Phone: <br />w <br />t tic. Signature of Alternate Facility (or Generator) <br />Mordh Day Year <br />a <br />z <br />y19. <br />Hazardous Waste Repart Management Method Codes (i.a codes for hazardous waste treatment, disposal and mcong systems) <br />LU <br />C3 <br />1. <br />2 <br />3 <br />A. <br />20. Designated FaaTtty Owner or Operator Certification of receipt of hazardous materials covered by 8ne manifest except as noted in hem 18a <br />PnntedlTyped Name nature Month Day Year <br />EPA Farm 870D-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />