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L O N <br /> Cn O� N N <br /> O Please print or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No.2050-0039 O N C <br /> Z I.Generalorl�NumbBr I-- O <br /> CAI onoiag <br /> UNIFORM HP.]_AR000S 2.Page 1 of 3 Emergency Rasppnse Ph ana 4.MiitTroaking Number N <br /> WASTE MANIFEST h 1 7 7 9 2 3 68 JJK .. <br /> D 5 GerteraloFs Name and Maili g Address ( <br /> Generators f Bile Add—(it dierect lhan mailing address) C (p <br /> IMPERIAL TRUCK WASH AND REPAIR JAZZ GROUP (D <br /> D 2142 W.YOSEMITE AVE OU <br /> JAZZ GRP INC ~' <br /> Z MANTECA CA GROUP <br /> 00 - <br /> Oenerafoes Phone, <br /> M 6.Transposer I Company Name 3 cD <br /> U.B.EPA ID Number D <br /> = AS <br /> BURY ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 6 < <br /> 7.Transporter 2 Company Name V.B.Epp ID Number <br /> P4 CD <br /> WORLDWIDE RECOVERY SYSTEM INC. <br /> 8.Ltesignaled Facility Name and Bile Addmss U.S.EPA 10 Number O <br /> YUMA YES LLC C <br /> 2730 E 13TH ST <br /> YUMA AZ 85365 <br /> Facility's Phone: A Z€t 0 0 0 5 1 5 9 2 4(029)344 9929 <br /> a1 <br /> ga 9b.U-S,DOT Description(indudirg Proper Shipping Name,Hazard Class,10 Number. 10.Containers 11.Tolai <br /> la.Waste Codes (D <br /> Hkf and Pardrirg Gnwp{if any)) No, Type 0uan5ty WLNol. 3 <br /> o t <br /> NON-i HAZARDOUS WASTE,SOLID(OILY SOLID,PAPER FILTERS) <br /> 5 a1 <br /> D M P rrDD <br /> w Ln <br /> uj rt <br /> w <br /> � O <br /> N <br /> V <br /> 3. V <br /> LD <br /> N <br /> W <br /> a) <br /> 4. W <br /> k O <br /> 14.Spewl Handling Instructions and Additional Information : <br /> N <br /> EMERGENCY CONTACT:CHEMTREC 1-804424-9300 WOES TERMINAL-CERES CS *PROFILES 981.:162623NR3Il i2 <br /> OJLYSOLID,PAPER FILTERS * *APPROPRIATE PERSONAL PROTECTIVE.EQUIPM€NT qf2pj7(j x� N <br /> v/ Q <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by It*proper shipping name,and are dassKted,packaged, <br /> marked and labeied/placarded,and are in all respects in proper condition for transport according to applicable inlemational and national governmental regulations,If export shipmenland l am me Pdmary r-r <br /> Exporter.I terrify that the contents of Eris consignment conform to erms of die attached EPAAcknowledgmenl of Consent. S <br /> I certify that the waste minimization statement identiried in 40 CFRth .27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. O <br /> ne rs/Offerors Prlatedfryped Name Si natu a Month Day Y. rte+ <br /> 15.Intema5onal Shipme is - <br /> Q <br /> F— ❑Impart to U.S. ❑Export from U.S. Port of enbyfexit: L <br /> Z Trans iters nature fore exports Ip i9 { � Y): Date leaving U.S:. OQ� <br /> 17.Transport rAckrowledgment of Receipt of Matedafs <br /> LLI� <br /> Transport nntedlT Na a Signature Month Day Year Ir <br /> QTransporter 2PrintedlTyped me Signature Month Day Year 0 <br /> ti <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space Ouani ❑Type ❑Residue ❑Paftfal Rejecton ❑Ful Rejection <br /> Manifest Reference Number, <br /> 18b.Alterrrate Facifity(or Generi U.S.EPA ID Number <br /> J_ <br /> U <br /> Facelltys Phone: <br /> w 18c.Slgnature oll Atterrlate Fadity(or Generator) Month Day Year <br /> a <br /> y19.Hazardous Wage Report Managernerrl Method Cadge(Le.,codas for heiaMpus waste treatment,disposal,and recyd n0 syatams) O <br /> i. 2. 3. 4. (p n <br /> O <br /> N Q <br /> 20.pillsIl aced Faddy Owner or Operator.CwWcaborl of reWo of hazardous mta wWs covered by the rlanifest except as noted In Item 18a <br /> Signature Month Day Year C_ <br /> (Rev.3-05) Previous ed8iorlaESIGhIATED FACILo <br /> ITY TO DESTINATION STATE(IF REQUIRED) 'D <br /> v W <br /> � rn <br /> (D N <br /> N O <br /> O <br /> W <br /> O <br />