Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050.0030 <br /> UNIFORM HAZARDOUS 1-Ganeralpr ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST I CAL 0 0 0 3 3 0 4 2 3 1 (800)424-9300 021522058 JJ K <br /> 5.Generator's Name and MaillnAddress Generator's Site Address(If different than mailing address) <br /> Q AND M,DSA TRACY CHEVROLET-QAN001 <br /> 3400 AUTO PLAZA WAY <br /> I RACY CA 9S:i["14 <br /> Generator's Phone: 209 83&4500 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> WORLD OIL ENVIRONMENTAL SERVICES CAD 0 2 8 2 7 7 0 3 8 <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC. CAR 0 0 01 7 5 4 2 2 <br /> 8,Designaled Facility Name and Site Add rass U.S.EPA ID Number <br /> YES MANAGEMENT, INC. <br /> 65W US HIGHWAY 95YUMA AZ 853E5 <br /> AZR000521146 <br /> Facilifys Phone: 92$ 9828 <br /> ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ED Number, 16.Containers 11,Total 12,Unit 13 Waste Codes <br /> HM and Packing Group(ilany)) No. Type Ruanlity WLNol. <br /> 1• NDN-RCRA HAZARDOUS WASTE,SOLID(OILY SOLID) 352 <br /> 0 L� <br /> D M d P <br /> Z 2. <br /> LU <br /> 0 <br /> 3- <br /> 4. <br /> 14.Special Handling ImtrMlions and Additional Informalion <br /> EMERGENCY CONTACT;CHEMTREC 1-800-424-9300 WOES TERMINAL:CERES CS NAEfM#981:171 *PROFILE 0 981: <br /> 162623QAN0010ILY SOLIDS/ABSORBENTS * *APPROPRLATE PPE EQUIPMENT ��r� 3 x,�S <br /> 35. GEHERATOR'SIOFFEROR'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 labeledJptacarded,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 certify that the contents of this consignment conform to the temns of M attached EPIA Acknawiedgroent of Consent <br /> I re"that ung waste minimization statement Wan ified in 40 CFR 26127(a)(d I am a large quantity generator)Dr(b)(if I am at1 quantity generator)is true. <br /> Generetor'srOfferors PrintedfT Name Slgnature Month Day rear <br /> KU�L I V 100t <br /> 16.lnte maWnal5hiprnents <br /> H ❑IrnpaitD U.S. Export kom U.S. art of entrylexit <br /> Transporter signature(for exports only): Date leaving U.S. <br /> W TT-Transporter Admowledgment of Receipt of Malerials <br /> LU <br /> Transporter 1 PrintedrTyped Name I Signature Mon'ii Day Year <br /> 0 rnC�v r 0 [ 7 <br /> Tran r 2 Printed(Typed Name sgrneture Mo tfi Day Year <br /> (�.IJS,Lt (Jn <br /> 18.Discrepancy <br /> :9a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full R2 ection <br /> Manifest Reference Number: <br /> 8b-Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> acllity's Phone: <br /> 1 Bo.Signature of Ahemate Fadlity(or Generator) Month Day Year <br /> W <br /> d <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes O.e.,codes for hazardous waste treatment,disposai,and recycling systems) <br /> LU 1. 2. 3- 4. <br /> 1 <br /> 20.Designated Fadfity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlT ed signalure Month Day Year <br /> EPA Form 8700.22(Rev.12-17) Pra us editions are obsdate. U 1 NATER FA LITY TO EPA's e-MANIFEST SYSTEM <br />