Laserfiche WebLink
Pledsa Drint or tvoe. (Form desnned for use on else (12-olichl Noewriler.) <br />Form Approved. OMB No 26504039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1 • Generator ID Numb* <br />CA 3Z 9 5'&.7 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />1916-371-574; <br />4. Manifest Tracklny Number <br />012478988 JJ K <br />WASTE MANIFEST <br />`6no <br />5. Generator's Name and Mailing Address Generatols Site Address Of different than mailing address) <br />'5A 1 1,111,Ps FC IG <br />z 3 & 23 S. 8'fl ,�+. ?rows cA <br />Generator's Phone: 77 J ^5000 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SACRAMENTO WASTE OIL CAL 913 534 912 <br />7. Transporter 2 Company Name U.S. EPA D Number <br />� S Si Z Z. <br />8. Desigmted FacmTity Name and Site Address U.S. EPA ID Number <br />Yuma Environmental Services, Inc, <br />2730 East 13th Street Yuma Arizona 86365A <br />FacWs Phone: 928-642-8936 AZR 4010 515 924 <br />93. <br />9b• U.S. DOT Description (rddrdrrg Proper Shipping Name, Hazard Class, ID Number, <br />10. ContaUhers <br />11. Total <br />12. unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pacldrg Group Of any)) <br />Ouantity <br />W11W. <br />1.S� <br />f <br />o <br />NDN-RCRA HAZARDOUS WASTE SOLIDS <br />00 L <br />D <br />l Zoo <br />P <br />j <br />z <br />w <br />2. <br />3. <br />4 <br />14. Special HanCFAg Instruclions and AddbDnal dorm 50n, <br />HANDLERS TO BE TRAIND AND USE PPE <br />15, GENERATOR'SIOFFEROR'S CERTFICMN: I hereby declare OW the contents of d is camrgment aro hfy and accurately described above by the proper shipping name, acd are dassified, packaged <br />and labeledomarded, and are in a4 respects In proper condition for transport accor thg to applicable Informational and national goverrimental mildatons. K export s W.wl and I am the Primary <br />Exporter, i certify that the contents of flys consignment conform to the terns of the attached EPAAdTa*%dgrnen<d Consent. <br />I certify that tm waste minim¢ation statement identified in 40 CFR 26Z27(a) (41 am a large quantity generator) or (b) Of I am a small quantity genemor) is true <br />Genera rota PrintedflT Name S99ture Month Day Year <br />J <br />f <br />116. <br />import to U.S. ❑ Export from US. Port of <br />a it <br />z <br />Transporter o(for exports only): Dale leaving <br />grmawre <br />V. Transporter Admwiedgrheml of Receipt of Matelots <br />Transporter Signature Day Year <br />1 tediTyped Naim <br />C <br />Trah< 2 } Name Month Day Year <br />05 <br />hv"A go r'` <br />18. iscraparny <br />18a. Oisaepancy lydketion Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial R*, ion ❑ FuM Rejection <br />Manifest Reference Number. <br />16b, Atternals Fadity (or Generalor) US EPA ID Number <br />J_ <br />V <br />mai <br />Facility's Phone: <br />18c. Signature of Attemate Facility (or Generator) <br />Month Day Year <br />4z <br />19. Hazardous Waste Repos Management Method Codes p.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />4� LA <br />2. <br />I <br />3. <br />4. <br />20. Desigrhated Pacirdy Owner or Operator. Certification of recelpl of hazardous materials covered by the manifest except as nded in item 18a <br />ignature Month Day Year <br />ftitecayped NamePaloll-, <br />-- i 1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />