Laserfiche WebLink
i <br /> 1 <br /> Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Guneralor tD Numtror 2.Page 1 of jmer gvY'f,��p ns P 4,Manifest Tfackln Number <br /> WASTE MANIFEST C A L' 0. 0 0 3 3 0 0 9 6 I �^' �s`t" ` � 0200 7889 JJ K <br /> 5.L U�fCC1'ZfVIHN��F{I l�1.7� !_4�fSC�M1�IVS f 1��1 l��mailiny nddros9) E <br /> PO BOX,987. 1030 S ARGONAUT STREET <br /> STOCKTON .CA 96201 STOCKTON CA 95206 <br /> Genewais Pliona' 2 0 9 4 6 9 - 7 9 .7 9 <br /> 6.Trans orlsr 1 Com an Name U.S.EPA ID Number <br /> FIR MOR 9NVIRONMENI-ALSERVICES INC; C A R 0 0 0 1 7 1 0 1 7 <br /> 1.Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC R: a O o 1 7 S 4 2 2 <br /> 8. t d,Fg and Sila Address U.S.EPA ID Number <br /> 2730,E 13TH ST—� <br /> YUMA-AZ 85385-.1901 <br /> Faciliiy'0hc6e: 928 344-9028A Z R 0 0 0 5 1 5 9 2 4 <br /> 98. 9b.U.S.DOT Descrbon(includin Roper$Ihipping Name,Hazerd Class,ID Number, 10,Containers <br /> 11.Total 12,Unit <br /> HM and Packing Group(if any)) No, Type Quantity 1Nl Nol, 13.Waste Codes <br /> 1 223 <br /> o <br /> ABSORBENT) <br /> &-Oo P <br /> z 2LU . <br /> 3. <br /> 4, <br /> 14.Spaciaal Huddling Instructions and Add�&onat Information t y O IS <br /> COO `)'"11k�5bi kl <br /> TiP J <br /> s.�s•z•a;ilr natnt-r1.in11v� s�� Contract#205907 <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I heroby 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 labeledlpincarded,and are in all respects in proper cond0on for transport according to applicable inle'matlonal and natloral governmental regulnlions,If export shipment and I am the Primary <br /> Exporter,I certify thel the conlenls of(his consignment conform to the terms or the attached EPAArknowledgment of Consent <br /> I certify that the waste minim zalion statement identified in 40 GFR 262.27(x)(if I am a large quantity generator)or(b)(if lam a small quantity generator)is true, <br /> GeneralDr slOfferor's Prin edlTyped Name Signature Month Day Year <br /> 3-155 dS .5 6 L 04 t}- 4CC <br /> 16.International5hipgrents <br /> F ❑import to U.S. 0 Export fru.U.S. ort of entrylexit. <br /> Z Transporter signature(for exports only); Date leaving U.S.: _ <br /> W 17.TransporterAdnowfedyrnenlorRece€pt orMalerials <br /> Transports 1 PrintodRyped Name Signature Month Day Year <br /> 13- <br /> o TC r7.�" (3 ' <br /> zTransporter 2 PfintedlTyped rName�' Signa ure., _ Month Day Year <br /> Ifs.Discrepancy <br /> 18a,Discrepancy Indlcallon Space puerilityyp <br /> ❑T e 0 Residua ❑Partial Rejection ❑Full Rejection E <br /> a tJlanifsst Reference Number; l <br /> 18b.Allernale Facility(or Generator) U-S.EPA 10 Number <br /> LL Facility's Phono', <br /> w 180.Signalure of Allemale Facility(or Generator) Month Day YGal <br /> a <br /> z <br /> N19.flazerdous Waste Report Management Melhod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. <br /> 20.Designated Facility Owner or Operator:Certilicalion of receipt of hazardous materials covered by the Manifest except as rifled in Itern 18a <br /> PdntodfType me Signature Month D//ayy, Year <br /> V1 <br /> EPA Form 8700122(Rev,12-17) Previous dilians ars obsolete. I.)I.;a !E .j' /1t;II.I i'Y TO VA's o-MANIFC-8T SYSTEM TEM <br />