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RECEIVED BY SJCEHD (EF) on 2/.21/2020 Please Driflf or tvoe. (.Form designed for usn nn niitn f17-nitrhi wnowea.r t e -4 16.InfemallonalShiomenis r-- ❑ Import Io US. ❑ Fxport from U.. � Port of entrylexil: z Transporter•signatufe (far exports only): Date leavfni) U.S.., 17. TransporlerAcimowledgment of RecpIpt of materials LU OTransporter 1 Prinleffyped Na er Signature aTransporter 2 Prinledflyped Name Sigrialure 18. Discrepancy 1ha. Discrepancy indication Space ❑ Quantity ❑Type ❑Residue 186. Alternate Facility (of Generator) Manifest Reference Number W Facif[Vs Phone: 18c, Signature ofNfernate Facility (or Generator) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, andrecycding systems) 26, Designated Facility Owner or Operator: Certtficalion of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba PrintedlTyped Name Signature 1 ❑ Partial Rejection EPA IO Number GA 0 ❑ Full Rejection (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESiINATI611 STATE pr RE001F?ED) tt11fFDR[ HAZARDOUS 1 Generator ti) Number 2. Pogo 1 of 3, Emergency Response PhoneJ4.Manifest ,.1 IFFI vv yam. V1111 .- -v-vUJJ Tracking Number WASTE INANtPEST _ w Av n 6u> 01746.7855 JJ K 3. Generators Name and Mailing Address Generator's Site Address (if differont Than mafling address) - c�01 L f_>t�4„1f'-;'u ;� f li(`t'.r , s 1-i�}.Ifr MICIN t. -N 1� 1 r)80 "?i1 !'.-98 l }ori S t LANE Generator's Phone: ='0 t 952-J.2222 aTOG#t U(j CA 95210 6. Transporipr 1 Company Name U.S. EPA ID Number r? )MI -D 01L. ENVIROM1VIENTAL SERVICL;: LAD 02827 7 0 36 7, Transporter2 CompanyName U.S. EPA ID Number WORLDWIDE IDE RE00WRY SYSTEM ING. CA -R00017-5422 8. Designated Facility Name and SileAddress U.S. EPA ID Number YUMA YES LLr 2730 E 13TH ST YIJIvIA ii7 8-53G5F1:- E=aCllity�sPhone: q•?, . c14-'=PT`y�; R O 0 0 5 1 5 9 2 0 ga, gb. U -S. DOT Description (including Proper 5hippinii Name, Hazard Class, ID Number. 10. Containers 1t. Total 12. Unit yM and Packing Group (i€ any)) Quantity Wt.fVol. 13. Waste Codes No. Type 0 1ig0N-RGRA HAZARDOUS VVASTE, SOOD (PAPER 1=1LT ESS; �- 352 - - r D M P z 2. LU c� 4. 14. Special Handling Insbucllons and Additional Information BI IERGENCY CONTACT : CPEMTREC 1-800-4214-03001WOES TEF2HNAL; CERES GS # PROF'll_E it 913.:16i623NRS-•PEP359 PAPER FILTERS f' * APPROPRIATE KRSONAL PR61'ECTI lE EQUIPMENT 16. GENERATOWSfOFFEROWS CERTIFICATION, I hereby declare [hat the contents of this consignment are fully and accurately desoribed agave by the proper shipping name, and are classified, packaged, marked and labeledfplacarded, and are in all wpects in propercondition for transpotl according to applicab€e intemational and national governmental regulations, If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknawledgment of Consent. 1 certify that the waste minimization statement Identified to 44 CFR 262.27(a) (i€ I am a large quantity generator) or (h) (IFI am a small quantity generator) is true. e -4 16.InfemallonalShiomenis r-- ❑ Import Io US. ❑ Fxport from U.. � Port of entrylexil: z Transporter•signatufe (far exports only): Date leavfni) U.S.., 17. TransporlerAcimowledgment of RecpIpt of materials LU OTransporter 1 Prinleffyped Na er Signature aTransporter 2 Prinledflyped Name Sigrialure 18. Discrepancy 1ha. Discrepancy indication Space ❑ Quantity ❑Type ❑Residue 186. Alternate Facility (of Generator) Manifest Reference Number W Facif[Vs Phone: 18c, Signature ofNfernate Facility (or Generator) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, andrecycding systems) 26, Designated Facility Owner or Operator: Certtficalion of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba PrintedlTyped Name Signature 1 ❑ Partial Rejection EPA IO Number GA 0 ❑ Full Rejection (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESiINATI611 STATE pr RE001F?ED)