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Please print or type. (Farm designed for use on elite (12-pitch) typowriter,) Form Approvers. OMB No. 2050.0039 <br /> 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone7017791345 <br /> anifest Tracking Number <br /> UNIFORM HAZARDOUS CAL 0 0 0 3 3 5 003 ( t100j 4'24-9300 JJ K <br /> WASTE MANIFEST <br /> r r' ar r Generators Site Address (if differentlhan mailing address) <br /> 5. Gen <br /> � , 1' Ott 4 C� bODGE JEEP RAIIA OF TRACY PRE14 <br /> 3460 NAG LEE ROAD <br /> TKAI:Y GA95311q <br /> 200- .420-1815 <br /> Generator's Phone: <br /> U.S, PIN6. TransGNumber <br /> A55� � F7CVNMENTALSERVICES <br /> 7. Trans Lt��i�79PIVECOVERYSYSTEMINC . U.S. EPA IDCAR00N00175422 <br /> 8. Des to Facll N.Ntm!nd Sile Address U.S. EPA ID Number <br /> T2730 E 13TH ST <br /> YUMA AZ 85365 AZR000515924 <br /> Facility's Phone: (928 )344-9828 <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 Wt./Vol, <br /> l • NON- RCRA HAZARDOUS WASTE , SOLID ( OILY SOLID , PAPER FILTERS) 352 <br /> o DM P T <br /> z 2 <br /> w <br /> 3. <br /> 4, <br /> 14. Spodal Handling Instruct bnsand Additional Information <br /> EMERGENCY CONTACT : CHEMTREC 1-800- 424-9300 WOES TERMINAL: CERES CS * PROFILE # 9B1 : 162623NRSPRE147 <br /> OILY SOLID , PAPER FILTERS * * APPROPRIATE PERSONAL PROTECTIVE , EQUIPMENT v a <br /> j <br /> 15. GENERATOR'S10FFEROR'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 labelediplacarded, and are in all respects In proper condition for transport according to applicable Intemationai and national govemmental regulations. it export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that a waste minimization statement identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (it ] am a small quantity generator) Is we. <br /> GenemI or PrintedtTyped Name Sig CD <br /> ay „ Year <br /> -� 16, tnte IlKal Shipments <br /> 0 Import to U.S. Export from U.S, Port of entrylexit: <br /> Z Transporter signature (for exports only): Dale leaving U.S.; <br /> w 17. TranspoderAcknowledgment of Receipt of Materials <br /> t2 Transporter 1 Printed/Typed Name Signature Man S41Y <br /> l (Q( <br /> QTransporter 2PrintedrType . Name Signature Month Day Year <br /> t- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ll Quantity ❑ Type ❑ Residue ❑ Partial Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> LL. FacilitysPhone: Month Day Year <br /> w 18c. Signature of Alternate Facility (or Generator) <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LLJ 1 2 3: 4. <br /> 20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed ped Name Signature Month Day Year <br /> EPA Form 0700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />