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3460 Naglee Rd. Record ID# PR0517826 <br /> 12/7/2020 Program: HW <br /> Photo 16: The following uniform hazardous waste manifest (021523871JJK) lacking signed designated facility copy. <br /> Farm Approved.OMR No-2050-0039 I <br /> Please print or type_ <br /> _ - UNIFORM HALLR00U5 t.c`"`relulONumber a-v7e1M 7.FmergmyRespaaePrrsr+a 4 f'121 '-5871 JJK � <br /> WASTE MANIFEST CAL 0 0 0 4 5 5 4 0 1 1 (a00)•24-9300 V L <br /> nMtlMadJmmuog9 ddyreess ! <br /> Dceft(.�ZF�1 ALCNtlU WE JEEP RAM ceneramre airAadress{d Oalerenlman msru,g eadresal j <br /> 3460 NAGLEE W) <br /> TRACY L'A 95304 r <br /> 209 6204800 V <br /> Geeemwrs Phatm. _ <br /> I.Transporter t compan Nana U'S�A D O 2 B 2 7 7 D 3 8 <br /> WORLD OI�VWIROHMENTAL SERVICES <br /> 7.Transponm2Gom an Name US-EPA I9 Nambar <br /> WORLD�M1'I6 RECOVERY SYSTEM INC. CAR 000175422 <br /> - �Nam V 5.EPA b Number <br /> a.Gee Ea s FMAHAGEMENT�INC� <br /> 66MOSHIGHWAY95 AZR0005211.46 <br /> - YUMA AZ a6385 <br /> Faoliys Phone. (928 9628 <br /> ga. 9b.V S_DOT D.—pa.(InAdIN pm,.hlpkrg Name.Hazard Lfaes.10 N--w. 1e.C:onWnem 11.Trial 12.Una 13.Wsate Codes <br /> HM aid PachinAG-phlary)) H. Type Ouenety WLIVd. � <br /> NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLIDS) <br /> DM i <br /> ru z. <br /> w <br /> l <br /> r. <br /> 4 <br /> 14.Spada[Haidling InsWctions end Addilianal Infonnalion I <br /> EMERGENCY CONTACT:CHEPATREC 1-W&424.9300 WOES TERMINAL:CERES C9 HAERG11961:171'PROF1lF IF 1: l <br /> TRA691-162623NRSOILY SOLIDS" ;APPHOPRIATEPIPE EQUIPMENT 2 y )5 1� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:[hereby Odom mottos convents of lh'rs consignmem ere lolly and acana0sly desoi6¢d abwa by thz proper shipPingnamh and,adassm th P,—,ed. <br /> maMad and fabeledrAlawrded,and ala in all respects In pmpercandilion W honorer according to applicable intemahonear d national 9mrTmer W revabem.II export shipnent and I am late Primary <br /> ExPorer,Iwmi,that the coolants of this cams rrmni camorm to the terms ri measacned EFAAWk Wi,gmenl d Crnoent for Shue <br /> I w tdy that the mamminimizalion slatemenl idennrted'm 40 CFR 262 27(a)(p I am a large 4uanmy g,,,e aiw or(b)(rl am a small quan4ry genera I <br /> Signature Menti pay Year <br /> Generaldsr0lfemra PHr,W Vryped Name <br /> 16.Intemabrnal Shipments Import W U.S- ❑Expmt ham US. Podolentryleut <br /> W Data leawy U.S. <br /> 3 Transportersignalum(for expectsMy) <br /> 9Z 17,TmnspormrAdu-MdgmentWReceiPlof Masedals y � Year <br /> 1—Tran rer I PrinmdRyped Namre SgnaWre (. 1. r <br /> d I Mpnht Day Year <br /> 2 TmnspDda 2 Pruned ped Name SiAnaWre <br /> 18.Discrepancy <br /> 18a.0i.empanay IndicaWn Space ❑Duanuty ❑Type ❑Residue ❑Partial Rock, ❑Fud Rejection <br /> Manksl Ralorance Num4er- <br /> 18b.Main to Fazllity for Generate-] U.5,EPA Numher <br /> V <br /> K �..My's Phone- Month gay Yea1 <br /> 4w 18c.Signatursof Allemate Faalilyfor Geraimlor) <br /> Y <br /> H19.Naurdous Waste Repod Management Method Codes(i a„Codes for haaardoua waste treatment,dlsposel,atd rBgyCVing systema) <br /> O 1 2. <br /> 3 4. <br /> 1 20 Designated Facility Owner or Operator.Ce 8f radon al receipt al hazy dour maledais cove ed try trio man lest ascepl as ndcd In Ilam 18a <br /> Pdntablryped Name Signature Mon81 gay Yeat <br /> EPA Form 8700-22(Rev,12-M Previous edihons are obso€ela GENERAT'OR'S HTlAL COPY <br /> JASON GAITAN, REHS Page 16 of 21 <br />