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101111111111111 <br /> Please print or type. Farm Approved.OMS No,2050,0039 <br /> UNIFORM HAZARDOUS t•Generator m Number 2,Page 1 of 3.Emergerxy Rasptx ss Pix Tse 4.MartfFest Tracking Number <br /> WASTE MANIFEST <br /> b.het eratf S Wame and Mailing Address ver�?ratar's S A}dnsss( <br /> rent that,,than mailing adcres� <br /> Dollar General #15928 Dollar General#15928 <br /> 20972'72100 12384 E. BLOSSOM COURT 12384 E. BLOSSOM COURT <br /> Generator's Phone: r g <br /> �r 1 Gam setas , <br /> U.S PA ID Namhitinniz Tint, 'k i <br /> ur <br /> 7. ra ,parte 2Com a t Na <br /> U.S. €; bar , <br /> 8. a €ed Fa i€ty Na SiteAddre A r <br /> Yuma Yes, >� <br /> 2731 E. 13th Street <br /> Yuma, AZ 85365 <br /> Facility's fa*,^,me ,;� <br /> 9a. 30:U.S.DOT S}escnDt un{i xgtdirg prig Stripping Name,Hazard Class,ID Number, 110,Gordainers <br /> HM asxt Pacttvtg Group(if any)) 11.Total 12 tuna 13.Waste Codes <br /> NO, Type ouarttity ltftr'Vot, <br /> ton RCRA hazardous waste, liquid (Consumer 1 DR 00103 P 3311' <br /> Z 2. __ E <br /> Uj <br /> 3. <br /> 4 ; <br /> l <br /> a <br /> A <br /> t <br /> a <br /> t � <br /> 14.Special Handling[nstn,ckos s arxf{tdditxrnaf tntcxrrbai Dn _ <br /> 1. 110524(Non-RCRA Liquid Waste (CA Only) - Loosepack) <br /> 15. GENERATOR'SIOFFEROR`5 CERTfFICAT*N; I Kw3 by declare that the aorrrter is of this consxgrrme}tare fury and accurate�Cescnbad a#ave by the proper sh€ppang eamo,and are cMe$&sed,Packaged, <br /> marked and?atieledtpiacarded,and are in all respects in ter Q01104W for transport according to applicable international and national governmental regtdai�rts.if expos shipment and t am the Prima y <br /> Exgcrter<I certify fy shat the contents of this consignment conform to fire*MIS of die attached EPAAckn�rq of Cortsard <br /> I certify that the waste minimization statement Identified in AO CFR 262 27(a,(g l am a targe quantity generator or `ill am a smart uantl <br /> } ()S q h geturatarl isrue <br /> . <br /> C;trneraCrv's/t7'.teror`sPriniecSl'fypedName S6gnatwe A9�;th Day ....Year <br /> -a 16,trtemat oral shiprr�ttts �1 <br /> Ii 0 Import to VS. / X€wrl from U.S. of en rexit . <br /> Transporter signature icor axports air ht __....._ <br /> #y)' Date a�rg U.S.: <br /> w17,Transpodff Arkrmovledgnxatt of Reow of Materials <br /> Traosponor'<PrinkiarFyped NameS€-nature <br /> p � ' mext€th Uay Year <br /> a !�N <br /> c e "rmth Day Year <br /> t VI <br /> 18a.D screpa kat on Space L l Quant ty �t <br /> TyPe Residue t l Partial Rejection fj Full R,etedlon <br /> hlanitest ftofererxx=Ntut<ber- <br /> }� 18b,Pateanate Facility(or C,-nerata) U S.EPA IQ Number <br /> t..1 <br /> u`E Faczliry's Phone' <br /> tt� 18c.Signature ofAftemate Facility for Generator) Month Cay Yezr <br /> 4 <br /> ?9.Hazardous Waste Report Manapi most Method t CrxfF s(i.e.,rides for hazardous waste ireatrrient,disPosat,and recycling systems} <br /> 1. 2 _ c <br /> 20.Designated Facility Owner or Operator,Certilicatlon of receipt of hazardous materials covered by the manifest except as noted in I -m 8a <br /> F nfed Type f4(Rev. r2-4117) <br /> Signature month Dzy Yoar <br /> EPA Form 870€) Previous edibions are obsolet <br /> ESIG A,j t. C6I i Y FO A'S fe-I 'CFI- TTU- <br />