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Please print or type. (Form designed for use on elite (12 -pitch) typewriter) <br />Form Aooroved. OMB No 2050-0639 <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. F_nbrpency Resporw Phone <br />4. Ata et racking NYmMr <br />' <br />WASTE MANIFEST <br />CA Liu;c9569 <br />1 <br />9}.6-371-574'. <br />1 81159 <br />JJ K <br />5. Generalors Name and Mailing Address Genaratofs Sb Address [d different than mailing address) <br />Bird Road Yard & Shop Facility <br />23623 S. Bird RdeTracye CA 95304 <br />Generators Phone: 510-715-8466 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />..UM WASTE OIL <br />CAL 913 534 <br />912 <br />7. Transporter 2 Carpsry Name <br />U.S. MID Wuntrer <br />Worldwide Recovery Systeme <br />CAR 000 175 <br />422 <br />S. Designated Fad6ty Name atb Site Address <br />U.S. EPA ID Number <br />Yuma Environmental Services, Inc. <br />2730 fast 13th Street Yuma Arizona db:i65 <br />Fadlity's Rwe 99-8-642-8938 <br />"ZR 000 515 <br />924 <br />9a. <br />9b U.S. DOT Description (Including Proper Shipping Name, HMWd pass, ID Number, <br />10 Contaners <br />11. Total <br />12. UM <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group IN any)) <br />Ouaribly <br />WIAoI. <br />o <br />1 <br />NOR-RCRA HAZARDOUS WASTE SOLIDS <br />-'t oo <br />-�- <br />� <br />� <br />(OILY SOLIDS) <br />P <br />p <br />Z <br />2. <br />3. <br />4. <br />14. Special Handling Insbuctim end Additiorrl INdmstlon <br />iiiiivlu nLRS TO BE TRAINED AND USE PPE <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlents of Cts consignment are fully and acaraWy described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplararded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. ff export sivpmenl and I am the Primary <br />Exporter, I certify that the contents of Cts consignment conform to Che terms of the attached FPAAdmoMedgment of Consent <br />I certify that the waste mhnkabm statement identified In 40 CFR 26227(x) ('d 1 am a large quantity generator) or (b) (N I am a small quantity generator) is true. <br />Generator'&Ufferors Printecifiyped Name Sgnahn <br />Month Day Year <br />J <br />F- <br />16. Intamab" Shipments <br />❑ Import w U.S. Export from U S. Pat of entryfexit <br />Z <br />Transponer signature (for exports only): Date leaving U.S.: <br />W <br />17. TransporterAdarowledrgnent of Receipt ofMatenals <br />tR <br />Transporter 1 PrintedlTyped Name Sgnattaa <br />"tr Day Year <br />P <br />Albers: Pi, hernazdea <br />ZQ <br />Transpotbr2 Prtntedityped Name Signature <br />Month Day Year <br />10. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouantdy ❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number. <br />18b. Atemate Facility (or Generator) <br />U.S. EPA 10 Number <br />J <br />U <br />Facility's Phone: <br />w <br />18c. Sgroture of Alternate Facilely (a Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e, codes for hazardous waste treatment, disposal, and recyding systems) <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Certification of recelpt of hazardous materials covered by Che manifest except as ruled len Nem 18a <br />PnintedlTyped Name Signature <br />Monet Day Year <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />