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Please print or Type. Form designed for use on ellte(12-pitch)typewriter, Form Approved.-OMB No.2050-0039 <br /> UNIFORM HAZARDOUS11 Generator ID Number 2.Pale 161'1'3.Emergency Response Phone 14,Manifest Tracking Number, <br /> WASTE MANI!EST ' 0 A I.0 0 01'9 4 3 0 7 3 (�C�}74;�7#4,V1C) w . 4689JJ <br /> 5.Generators N ne and Mailtn Address Generators Sile Address(If dlfferenl than malting address) . <br /> PSI' S � _ - <br /> 201 V,OR014ARD STREET <br /> HAtVlMONTON SIJ 08037 : 401800 T V1 E;HOC KEE)ANE <br /> Generators Phone: <br /> b his £)175 LODI CSA 96240 <br /> s.Transporter 1 Company Name U.S.EPA ID Number <br /> WORLD.OIL ENVIRONMENTAL 8ERVIGE; (;A D 0 2 8 2 7 'i p 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WUk COWIDE REGOVERY SYSTEM INC,. G A R C1 G 0 f 7 61 A 2-2 <br /> 8.Designated Facility Name and ss <br /> e <br /> SiteSileAddr �1)S E"P .. er1 <br /> :r riso[el• iY1 � ,fa � CLQ}ra4Lt]!.SL�?s"r kms'-?`_'--�'��'!e1\avb�=3.:favQ✓fYi.:eift5A�1t/Es`/.='.`.�.i;� <br /> 2130 E:4.3TH ST <br /> YUMA AZ 85365 AZR000515024 <br /> FaclA s Phone; 922.344-;928 <br /> 9, 9b.U.S.DOT Description(Induding Proper Shipping Name,Hazard Class,ID Number, 10.ConWners 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) Na. Type Quantity WI.7Vol. <br /> 1•NOWNCRA W—AHE0108 WWI E,SOLID(BRAKE I I HIE SPAVINGS) C 1 1 <br /> o <br /> 4. <br /> 14.Special Handling Instructions andAddilional Information <br /> /1 j <br /> C-MEROIaNCY CONI ACT :trMEMTHEG 1.-800-424-9300I�VOFS TERM AL:CPR F8 08 <br /> BRAKE LATHE SHAVIN'0 it if API HOPRIATIM PPF Iv UIPMEN1 "a <br /> 15. GENERATOR'SIGFFEROR'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 labeledlptacardad,and are In all respects in proper condition fortransport aocording to applicable International and national governmantat regulations.tf expo€1 shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform 10 the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 282.27(a)(if I am a largo quantitygeneralor)or(b)(if I am a small quantity ganarator)Is true. <br /> Ganaratoeslo erors ftledfryped Name Signature Month Day Year <br /> j 18.International shipments <br /> r ❑Import to U.S. ❑Expod from U.S. Port of enbyleAl: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAdmowledgment of Receipt of Materials w <br /> Month Da Year <br /> 'joTr alar 1 Prinledfryped N e � Signature �- Y <br /> 7ransporler2 Pdknted/Typed Na @ f Signnattuu e Month /Day,' Yfear <br /> 18.Discrepancy 41 <br /> 18a,Discrepancylndication Space �I <br /> P ❑ Quantity i__.1 Type ❑Residue � ❑Partial Rejection ❑Full Releciion 1. <br /> Manifest Reference Number: <br /> 18b,Allernate Fadlily(or Generator) U.S,EPA ID Number <br /> U <br /> Facility's Phone: <br /> 18c.5ignalare ofAllernate Facility(or Generator Month Day Year <br /> f..,. .- r�r - --�- �ri^a'�5�;�r'r-�%difPrsr Jnr r:' r r`i.s�;�.�'i✓��Y 'iy <br /> - -�rY�.s.�xf+"3'�rF�'.�r`Ys#t� �..�:.a€�t.r_.`s"s•�:>�k:x�fsRP Yvx.�.A <br /> .v r3Ec ,• r <br /> y19,Hazard6us Waste Report Management Method Codes Q,e„codas for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1 2. <br /> 20.Designated Facility OmerorOperator:Cenificallon of receipt of hazardous materials covered by the manifest oxovoq ncted in Item 188 <br /> Print d ped Namq Sgnaturai Month Ray Ye5. <br /> CA <br /> EPA Form <br /> 1-22(Rev.3.05) Previous editions are obsolete. ''C IGNATED FACILITY TO GENERATOR <br />