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Please print or tgz- (Form designed for use on elite (12.01nh) ly-pewriter.) <br />Form Approved. OMB No 2050-0039 <br />EPA Fonn 87D0.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1 GeneratarlD Number <br />2 Page 1 of <br />3 Emergency Response Phone <br />4. s 4rnEer <br />r 2 2 <br />WASTE MANIFEST <br />CAI.000.2gS69 <br />- <br />C l JJ K <br />5, Generator's Name and Mal ng Address Generators Site Address d diflerenl than m4ing address) <br />Bird Road Yard & Shop Facility <br />F.U, <br />li �-11�CIE� V <br />23623 S Bird Rd,Tracy, CA 9530. U v <br />--aerators Doone 510-715-8466 <br />6. Transporter 1 Company Name <br />titij Z I ZU11 <br />U.S EPA D Number <br />SACRAMENTO WASTE OIL <br />:r <br />7. Transporter Caerpa;ty Nems <br />X L',jb r U N <br />U.S. EPA ID Number - <br />'orldvide Recovery Svatems <br />EQUIPMENIT DIVISION <br />6. Desgnaled Facdoty Nene and Sib Address U.S. EPA ID Number <br />Yuma Environmental Services, Inc. <br />2730 East 13th Street Yum Arizona 86365 <br />Facili?sPhone 928-642-8938 <br />9a. <br />9b U S DOT Description ;including Proper Shipping Name, Hazard Class 'D Number <br />10 Candahers <br />11. TOW <br />12 Unit <br />- - - 13 Waste Codes <br />No <br />Type <br />HM <br />and Parkrg Group it onyl) <br />Quantity <br />WLN01 <br />1 <br />NON-RCRA HAZARDOUS WAS'T'E SOLIDS <br />00-: <br />- <br />� <br />(OILY- <br />Z <br />2. <br />LU <br />- -- .; <br />3 <br />4 <br />14 Specht Har4WV msbtKtloro and AdMional lrNoratatlon <br />IiANDLERS TO BE TRAINED AND USE PPE <br />15 GENERATOR'StOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of" consignment are fully and accurately desc bed 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 intemobwal and national governmental regulations If export shipment and I am the Primary <br />Exporter I certify that the contents of Gres consignment conform to the terms of the attached EPAAddnm*dgment of Consent. <br />I certify that the waste minimizalon statement identified In 40 CFR 262271a) (f i am a large quantity generator) or ;b) (d I am a small quantity generator) b We <br />Generator'slOfferor's PrintedlTyped Name Sgnatude Month Day Year <br />P- <br />16. kYernalfardal Shipments <br />mport to U S ❑ E.P rt from U.S. Port of entrylexit - <br />Z <br />Transporter signature (Im exports only) Dale leaving U.S <br />ir <br />17 Transporter AdmaMedgmerd of Receipt of Materials <br />Signature Month Day Year <br />Transporbr 1 Pdintedtiyped Name <br />to <br />�lberi ii. itcruantcx <br />Zit <br />Transpor*2 ftbaypedName Sgnatvre Month Day Year <br />18 D*--vpanuy <br />18a. Discrepancy Indication Space C f' C Type F Residue ❑ Partial Resection ❑ Ful Resection <br />Manifest Reference Number. <br />18b. Akemate Facility (or Generator) U.S EPA 10 Number <br />..a <br />V <br />Fadxlitys Phone <br />C3 <br />18c Signature of ARemate FaciAy or C*n@mtor) <br />Month Day Year <br />a <br />Z <br />N19 <br />tcatardous Waste Report Management Method Codes I .e . codes for hazardous waste treabnent, disposal, and recycling systemv <br />1 <br />Z <br />3 <br />4 <br />20. Designated Facility Omer or Operator Caditbw of receipt of hazardous materials covered by the manifest except as noted in Rem 18a <br />PrntedlTyped Name Signature Month Usy Year <br />EPA Fonn 87D0.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />