Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-r" <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000178438 1 800-746-7449 <br /> 023581007 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ACME BOW <br /> 204 E MAIN ST <br /> ��hn STOCMN,CA 15205 <br /> Generator's Phont"y-948-6736-105 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY 1fiASTE OIL,INC CARD002733DV <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEMS INC CAROOO175422 <br /> 8.Designated Facility Name and SileAddressYUMA YES 2 WASTE TRANSFER FACILITY U.S.EPA ID Number <br /> 6500 US HIGHWAY 95 ARZ000571148 <br /> YLIMA,AZ 85365 <br /> Facility's PhoneQ28-3444 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers ti.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quw" WtNol. <br /> 0: 1 NON-PC,-RA HAZARDOUS WASTE SOUDS,ABSORBENTS 8 OIL, 1 DM 180 P 352 <br /> PAPER MLTERS <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE# 2001257NRS ABSORBENT ERG 171 <br /> EMERGENCY CONTACT:JOHN <br /> Wo#y23 , <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acaralely desatbe'above by the proper shvprg name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international end nelonel govenvnentol regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(BI am a erne)*mr"gerwabr)is true. <br /> Generatoes/Ofi a PrinWyped N� Day Year <br /> ,`'J] �. Y7x-- O <br /> 16.International Shipments <br /> F ❑impyt.U.S. ❑Export from of enlryma <br /> ? Transporter signature(for exports only): bevtg U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI� <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> c <br /> A- <br /> a- 7o <br /> z Transporter 2 Prttedfryped Name Month Day YeIr <br /> )Z 13 1 Z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑ResidueEl Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. I 2. 3. 4. <br /> 1 <br /> 20.Designated Facility Owner or Ope r:Certification of receipt of hazardous materials covered by the manifest except as ncted in a 18a <br /> Printed/Typed Name Signature Month DayYear <br /> UCtOle,k <br /> EPA Form 8700-22(Rev.12-17) P ious itions are obsolete. ESIGNA FACILITY TO EPA's e- ANIFE T SYS M <br />