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Please print or type.(Form designed for use on ekte(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 P.Page 1 3.Erne Response Phone 4.Mantfest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 6 6 211 1 (800)424-9300 016774314 J J K <br /> 5.Generators Name and Mal" Address. Generators Site gess('d different than mailing address) <br /> FIRESTONE#O�L8746 <br /> 720 E.HAMMER LANE <br /> STOCKTON CA 95210 <br /> Generators Phone: 209 951-2403 <br /> 6.Transporter 1 Compag Name U.S.EPA ID Number <br /> ASBURNVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8:Designated Facii Name aryl Site Address U.S.EPA ID Number <br /> YUMA YES LLC <br /> 2730 E 13TH ST. <br /> YUMA . AZ 85365 A Z R 0 0 0 515 9 2 4 <br /> FaaG Phone: (928)34+-9828 <br /> ga. 9b.U.S.DOTDescription(mckrding Proper Shipping Name,Hazard Class,ID Number, 10.CorAmw re it.Total 12.Unit 1,3.Waste Codes <br /> HM and Paddnli Gawp(if any))'` No. Type Quantity Wt.Nd. <br /> I. NON-RCRA HAZADOUS WASTE.SOLID(NON-CONFORMING FILTERS) j L` 3 <br /> D M P <br /> w <br /> z. <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional lnfornation <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300*APPR RIATE PERSONAL PROTECTIVE EQUIPMENT*EMERGENCY <br /> CONTACT CHEMTREC 800 424 9300* TRUCK PROFILE#163153NRSFIR627 <br /> 15. GENERATOR'UPEROWS CERTIFICATION:'thereby declare that bus contents of this consigninent are filly and accurately desorgW above by the proper shippNg name,ard are classified,packaged, <br /> marked and hibeledlIplacarded,and am-in all respects kr propercondifion fortransport according to applicable Intemational and national governmental regulations.If export shipment and I am the Primary <br /> I rkvtify that the contents of this.consignment conform to 04 terms of the attached EPAActmoatedgiment of Consent <br /> I certify that the waste mI2Ln2!!T statement ldwjfied Inp CFR (a)(d t am a large quantity' tDr)or(b ff a sural quantity generator)Is true. <br /> Generate s P ad . -I-) I mom *Da Yew <br /> I 0 l 1 <br /> ..r 16.Intematioipet VVVwv <br /> . ❑Irlpzitf�'U:S. ❑EkpiAtlrofh'U:S. Pot'ofenkq/exit <br /> Transporter signature(tor exports only): [late leaving U.S.: <br /> 17.T AdawMedgmntof Receipt of Matedats <br /> 12 k Transpolar 1 Printed/Typed Name jSignatureEL <br /> 0. <br /> Transporter 2 PrintedlTyped /1 f/J F/ Signature fffM Day Yew- <br /> 18.Discrepancy <br /> 18a Discrepancy IndkatUon Spm ❑ Quantity [:]Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Afternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> FaciWs Phone: <br /> 180.Signature of Alternate Farity(w tor) Month Day ' Year <br /> d <br /> z <br /> H19`Hazardous Waste Report Management Method Cates(i.e.,codes for hazardous waste treabnent,dlsposai,and recycling systems). <br /> t. 2." 3. 4.. <br /> 2O.DesilgnatedFaclfily Owner or Opembtr:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printed/Typed Nam S hionthDay Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />