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Please print or type.(Form desi nad for use on ellte{12• itch)t1pewriter.) Form Approved.OMS No.2050-0039 UNIFORM HAZARDOUS 1 Generator 10 Number 2 Page 1 of 3.Emergency Response Phone 4,Mantfost Tracking Number WASTE MANIFEST I CA LU 00330423 1 424-53U'j 917695169 JJK 5.Generators Name and Melling Address Generator's Site Address(If different than maiUng address) r;f},f:, Wi. DBA TRACY CHEVROLET •QAN001 3400 AUTO PLAZA WAY TRACY CA 95304 Generators Phone' �09 835 4500 6.Transporter 1 Company Name U.S.EPA 11)Humber ;'dORLD 0I ENARONMENTAL SERVICES u a o c < < < c 7.Transporter 2 Company Nance U.S.EPA ID Number WORLDWIDE RECOVERY SYSTEM INC- CAR 0 0 0 1 7 5 4 2 2 a.Designated Facility Name and Site Address U.S.EPA iD Number YES MANAGEMENT. INC. C500 US HIGHWAY 95 YUMA AZ 85365 A Z R fl 00521146 Facility*Phone: q'' ct -R ga. 9b.U-S.DOT Description(indudirg Proper Shipping Name,Hazard Clasa,ID Number, 10,Containers 11.Total 12,Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity VAMI. 1'NON-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID) 2. 3. 4. i 14.Special Handling InsWcticns and Additional information EMERGENCY CONTACT : CHEMT REG 1-800-424-9300 WOES TERMINAL:CE S CS NAERG#9131 . 171 *PROR #8131 162623QAN001 QTLY ABSORBENTS * * PR1 PPE EQUIPMENT YNN 15. GENERATOR'S16FFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationaland national governmental regulations-If export shipment and I am the Primary Exporter,I certify ata!the contents of this cansigrnment conform to ate terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimlaaAon statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or b rator)rs true. Generator Nam Montlt Day Year 16.Intemalicn e s Port Of entrylexlt: Impart to U.S. Ex Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials F Transporter 1 Pdntedrryped Name t SignatureMonth Day Year M Transpona<2 PrintedlTyped Name Signature Month Day Year ce 1 1133 12-0 Q 18.Discrepancy 18a.Discrepancy indication Space El ❑uankly ❑Type ❑Residue ❑Paial Rejection ❑Full Re) ection S Manifest Reference Number. 18b,Altemate Facility(or Generator) U.S.EPA 1D Number J U rQs Facgilys Phone: LLI 18c.Signature of Altemale Facility for Ganeralor} Pdonth day Year Z 113,Hazardous Waste Repot Management Method Codes(i.e-,codes for hazardous waste treatment,disposal,and racycling systems) � 1 \A\Lk` 2 3 4. 20,Designated Factlily Owner or Operator:Certification of receipt of hazardous materials covered by ate manifeat except as noted in Item Ise Prin Name Signature Month Day g LA Z2 EPA Farm 8700-22(Rev. -05) Previous inions are obsolete. aESIGNATEO CILITY DESTINATION STATE(IF REQUIRED)