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Please crint or Noe. ; Form desiuned for use on elite (12 -pitch) typewriter) <br />Form AFFroved OMB No 26500039 <br />crm 870022 (Rev 3.05) Previous ed tions ata obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />6A SL Ki <br />2 Page 1 of <br />1916-371-5747 <br />3. Emergency Response P.c:.e <br />4. Manifest Trackin❑ Number <br />1012478988 JJ K <br />WASTE MANIFEST <br />1 000 -37,1 <br />I <br />5. Generator's Name and MaEng Address F GeneratWs Site Address (d different than maiffvtg address) <br />r <br />r , Ck (cYIS��{relftr. <br />Generators Phone " ?-7 <br />6. Transporter 1 Company Name U.S. PA 0 Number <br />SACRAMENTO WASTE OIL CAL 913 534 912 <br />7. Transporter 2 Company Name U.S. EPA D Number <br />8 Designated Fa:'ity Nance and Site Address U S. EPA ID Number <br />Yuma Environmental Services, Inc. <br />27:�? East 130 Street Yuma Arizona 86365a <br />FacilitVsPncne: 926-642-8938 AZR GOO 515 924 <br />9a <br />9b U S DOT Description including Proper Sh#ing Name Hazard Class ID Number <br />10 Containers <br />11 Total <br />12 Unit <br />13 Waste Codes <br />No <br />Type <br />HM <br />and Paddrtg Group (d any <br />Quantity <br />WLNoi <br />1. <br />o <br />HOH-RCRA HAZARDOUS WASTE SOLIDS <br />-) <br />W <br />LLI <br />(� <br />L <br />� � <br />3. <br />4 a <br />14. ofd Addttbrrel <br />HANDLERS TO BE TRAINED AND USE PPE <br />ERG # 128 <br />15 GEW-BATOR SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ata fu8y and accurately described above by the proper shipping rams, and are classed. packaged• <br />marked and labelediptacarded, and are in all -aspects n proper condition for transport accordtN 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 confamt to the terms of the attached EPAAcknowledgmenl of Consent. <br />I cmtily that the waste miNmaation staternent Iden"ed in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) :d l am a small Quantity generator) is Ince <br />GeneraWs."ervesPrtnted,Ty*Name Signature Nutt Day Year <br />-1 <br />(: <br />16. International Shipments <br />/@& <br />❑ Import to U S El Export from U S Pon of "/@& <br />K <br />Transporter signature (br exports only;. Date leaving U.S <br />ft <br />17 Transport"AdnovAedgrnent or Receipt of Materials <br />Transporter 1 Printed/Typed Name Sigrnhee Month Day Year <br />QTransporter <br />2 ;,ri .yped Name - SgaaWre Match Day year <br />a <br />H <br />18 Discrepancy <br />tBa. Discrepancy nditatlon Space ❑ Quantity ❑ Type J Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b Altemate Facky (or Generator) U.S EPA ID Number <br />J <br />U <br />Faoldys Phone <br />WI <br />8C Signature of Alternate Fatty (or Generator) <br />Month ay Year <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (. e . codes for hazardous waste treatment. disposal, and recycling systems) <br />� <br />1 <br />2 3 <br />4. <br />20 Designated Faality Owner or Operator Certficatlon of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />i. <br />Pnn•.EG yped Name Signawre Mon:n Day Year <br />1 <br />crm 870022 (Rev 3.05) Previous ed tions ata obsolete. GENERATOR'S INITIAL COPY <br />