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Please Dant or type (Form destined for use on elite (12-oitchl typewriter) <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 o1 <br />3 Emergency Response Phone <br />14. Mrs <br />rocmger <br />1iy1� <br />_WASTE MANIFEST C A L000329569 <br />916-649--0144 <br />..J6 JJ K <br />5 Generalors Name and Mating Address Generator's Sete Address (N d'i8erera than mailing address) <br />_fa i rauui x arc & Shap Facility - <br />3623 S. Bird Rd, Tracy, C A 95304 <br />Generalols Phone: 510015-8466 <br />6 Transporter 1 Company Name US EPA 10 Number <br />6ACKAPiENTO HASTE OIL 913 534 912 <br />7 Transporter 2 Canpany Name U.S EPA IDNumber <br />t? orld wino Recovery Systc m Inc. CAR 000 175 422 <br />8 Designated Facility Name and Site Address US, EPA ID Number <br />Y u Lla EnvjxQa w enwi Servlrces, Inc. <br />Ess! 13th Street~ Yuan, Arizona 85365 <br />Fa i sPhone 927"42-8938 1 A Z R 000 515 921 <br />9a <br />9b U.S DOT Description (including Proper Shipping Name, Hazard Class, 10 Number. <br />10 Contafnam <br />11 Total <br />12 Unit <br />13. Waste Codes <br />No <br />Type <br />HM <br />and Packing Group (N any)) <br />Quantity <br />WlNol. <br />o <br />1 <br />NON-RCRA HAZARDOUS WASTE SOLIDS <br />3 <br />(OILY SOLIDS) <br />P <br />Z <br />2- <br />111i <br />t9 <br />3 <br />4 <br />14 Special Handling fnshuc;tIons andAddlien d WameVon <br />"ANVILERS TO BE TRAI14ED AND USE PPE <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: i hereby dedare that the contents of this consignment are fuay and accurately described above by the proper shipping name and are classified, padraged, <br />marked and labeledlplacarded, and are in all respects in proper rnndition for transport according to applicable International and national governmental regulations. H export shipment and I am the Primary <br />Exporter, I certify Vial the oontents at this consignment conform to are temp of the attached EPAAduaMedgmenl of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) IN I em a large quantity generator) or (b) (d I am a small quantity generator) Is true <br />Genera;ppfferors Printect Typed Name Signature Month Day Year <br />J <br />F_ <br />16. Intemmaational Shipments <br />❑ Import to U.S. Export hon U S. Port of entrylexit <br />Transporter signature (for exports only): Date leaving U 5 <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter PdntedTTyped Name ature Day Year <br />rY <br />1 �. -- .• <br />0. <br />QTransporter <br />2 Pnniedrryped Name Signature Month Day Year <br />18 Discrepancy <br />1&a. Discrepancy, indicalion Space ❑ QuanVly Type Residue ❑ Partial Rejedion ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U S EPA ID Number <br />U <br />Facility's Phone <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal and racyc ing systems) <br />UA <br />1. <br />2, <br />3. <br />4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted In Nem 18a <br />[R�� Name SignaWra Month Day Year <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />