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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 2 6 413 2 1 (800)424-9300 017 6 96911 JJ K <br /> 5.Gen ef§Igr's.NOma.aOd Main?AVno111002 Generators SiteAddress(if different than mailing address) <br /> PO BOX 3191 NG I <br /> MODESTO CA 95354 2714 STAGECOACH <br /> Generators Phone: 209943-4730 STOCKTON CA 95215 <br /> 6.Transporter i Company Name - U.S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICESCAD 0 2 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC. CAR 0 0 017 5 4 2 2 <br /> 8.Designated Facility Name and 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 /> Facoi 'a Phone: 928344-9828 ' <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WIN& <br /> t NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID, PAPER FILTERS) 352 <br /> ®OZ Dm 4C-)UP <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT : CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS *PROFILE#9B1 :162623NRS711002 <br /> OILY SOLID, PAPER FILTERS * *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT w�a 53 1 if s <br /> 15. GENERATOR'S/OFFEROR'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 labeledlplamnded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I ceNty that the contents of this consignment conform to the terms of the attached EPAAcknowletlgment 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)to I am a small quantity generator)is true. <br /> GeneratorslOfferors Pnnted/Typod Name Signature Month Day Year <br /> J 16.International Shipments <br /> f— <br /> El import to U.S. Exponfrom U.S. Pod of entrylexil: <br /> z Transporter signature(for exports only): - Date leaving U.S.: <br /> Oc 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnntadrryped Name Signature Month Day Year <br /> or 0l /1 <br /> Q Tr nsporier 2 rintedRyped Name Sign a Mon ay e <br /> ar <br /> .p 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residu ❑PartialReledion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Altemale Facility(or Generator) US.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> 18a Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 20.Design ted Facility Owner or Operator:Certification of receipt of hazardous metedels covered by the man' _,cerN noted In Item 188 qq <br /> JII' <br /> Pride tlR pe Name ignat re M th D Year <br /> EPA Form 8760-22(Rev.3:05) Previous editions are obsolete. DE NATED FACIL YTO DESTINATION STATE a((IF REQUIRED) <br />