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Please print or type. (Form designed for use on elite (12 -Pilch) typewriter) <br />Form Approved. OMB No. 2050.0039 <br />EPA Form BIUU-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of3. <br />Emergency Response Phone <br />4. Maphat Nuetber 7 a. <br />WASTE MANIFEST <br />C A L00032956 <br />91"49-0 <br />J J K <br />5. Generators Name and Mailing Address Generators Site Address (H different than mailing address) <br />bird Road Yard & Shop Fa.:i y <br />2362° S 3trd Rd, Tracy, CA 95304 <br />Generators Phone: 510-715-8466 <br />5. Transporter 1 Con•pany Name U.S. EPA ID Number <br />ACRAMENTO WASTE OIL .;AL �)1J 534 912 <br />7. Transporter 2 Company Name U S. EPA ID Number <br />orld wide Recovery Syate m Inc. CAR 000 175 422 <br />6. Designated Facit, Name and Site Address U.S EPA ID Number <br />h ume Environcental Services, Inc. <br />2-730 Eclat 13Th S -. ,, 't. Yuba, Arizona 85365 <br />Fadirt's Phone: 92€3-642-8938 A Z R 000 515 926 <br />9a <br />91b. U.S. DOT Description (induding Proper Shipping Name, Hazard Clara, ID Number <br />10 Containers <br />11 Total <br />12, Unci <br />13 Waste Codes <br />No <br />Type <br />HM <br />and Paddng Group (f arry)) <br />Quantity <br />WINot <br />o <br />1. <br />NON-RCRA HAZARDOUS HASTE SOLIDS <br />--. <br />(OILY SOLIDS) <br />._ <br />Z <br />2. <br />w <br />3. <br />4. CON <br />SHIC <br />T DIVISION I <br />-- -- - <br />14 Special Handling Instructions and A464mal Information <br />A8DT,FRS TO BE TRAINED AND USE PPE <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name arta are classified, packaged, <br />marked and abeledrplacarded, 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 EPAAdmowledgment of Consent <br />I cardy that the waste minimization statement Identified in 40 CFR 262.27(a) (H I am a large quantity generator) or (b) of i am a small quantity generator) is true <br />GeneratoeslOHeroes PrintedlTyped Name Signature Month Cay Year <br />16 Inlemabonal Shipments El ❑ Import to U.S. ri from U.S Port of entrylexit <br />z <br />Transporter signature (for exports only): Dale leaving U.S- <br />.S. <br />IX <br />w <br />17. Transporter Acfuroa4edgment of Receipt of Materials <br />jj <br />Transporter 1 Printed/Typed Name Sgnatum Month Day Year <br />a <br />rn <br />1!bnra R . b l . <br />- <br />za <br />Transporter : ✓nn ndTyped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue U Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U S. EPA D Number <br />U <br />LL <br />Facility s Phone: <br />w <br />_j_ <br />16c. Signature of Atla rate=acrlity (or Generator) <br />ManN Day Year <br />a <br />Z <br />y14 <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatinent, disposal, and racydin9 systems) <br />0 <br />1 <br />2. <br />3 <br />4. <br />20 Designated Facility Owner or Operator Certifxabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />'rinteiR,ned Name Signature Month Day Year <br />EPA Form BIUU-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />