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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gen ra r I N mbe ,rte 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST J / 1 888-785-7225 1 012800'971 F L E <br /> 5. operators Name and WilinTAddress �, Generator's Site Address(if different than mailing address)44X- <br /> -C S�ip�i�� 4w�1 I�c�'f1L� Pacific Shipping and Trucking Co. <br /> 8667 Jacob Brack Road 18667 Jacob Brack Rd. <br /> Lodi, CA 95242 Lodi, CA 95242 <br /> Generalors Phone: 2093295916 <br /> 6.Transporter 1 Company Name U.S.FPA ID Number <br /> Advanced Chemical Transport Inc./DBA ACTENVIRO CAR000070540 <br /> 7.Transporter 2 Company Name U.S.EPA to Number <br /> Worldwide Reco\ery System, Inc CAR000175422 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Yuma YES, LLC AZR000515924 <br /> 2730 E. 13th St <br /> Yuma, AZ 85365 <br /> Fadbly's Phone: 928.344-9828 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Padding Group(n any)) No. Type Quantity WtNol. 13.Waste Codes <br /> 1•Non-RCRA Hazardous Waste Solid(Oily Solids) / DF I`/ � P 352 <br /> 0 <br /> Z 2. <br /> w <br /> r, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Inforrmation Project Number 200410 Document#: D239878 <br /> 1) 1811776 TRY-M^O <br /> 110 <br /> (0 - l 4 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described 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 Intemationaland national governmental regulaftons.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ill am a small quantity generator)Is true. <br /> M <br /> atorsfOffe r PrintodlTyp me Signature Mon Day Y ar <br /> SS &1 LJ- <br /> _s C <br /> 16.International Shipments <br /> ❑Import to U.S. D Export from U.S. Port o1 entry/exit: <br /> ? Transporter signature tforexports only): Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Rece t of Materials <br /> Tra or to yged Name Sf Mon Day Y r <br /> 0 2��q 041 to im <br /> a <br /> Tra iter 2 Prinyped Name Slgna Mon Day Year <br /> # o �tc <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Fealty(or Generator) i U.S.EPA ID Number <br /> J <br /> U <br /> Faalilys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> U519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certificatlon of receipt of hazardous materials covered by the manifest except as noted in Item 1Ito <br /> Prfnted/Typed Name Signature Month Day Year <br /> �bhi,o()L4� Q1, , I Aackil I �Z IZ-CA (21 <br /> EPA Form 8700-22( ev.12-17) Previous editions are obso e. D ED FACILITY TO EPA's e-MANIFEST SYSTEM <br />