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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GeneiatdrfD Number 2."Page 1 of 3.Emerge' y Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST CAL0003 t [[u y a v F <br /> 5 Generator's Name and Mailing Address " Generator's Site Address(if different than mailing address) <br /> CAL€F RNIA 81-ATE,PAPIKS,CARIkdIMGIE SVRQ EAS" <br /> 15751 TELARU 1 <br /> OVER - r Dt 3 COR7t3 1i � i _1# f Ot t. ► 'mig <br /> Generator's Phan s: "fit ;_ `f-f' C r`.�A )53'76 <br /> B.Transporter 1 Company Name U.S.EPA ID Number RXW District <br /> r+VIERICA,N'VvILLEY T A T E r IL6 ft:;. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number 1 <br /> S DinaCeitF8t11tjNdritidvtT. <br /> e<... <br /> YUMA YES 2 WASTE TUNSFER FACILITY <br /> i-5100 US HIGHWAY 95 <br /> UW,AZ 85365 <br /> Facility's Phonect. <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Godes <br /> (7 # Ft 4� t LtSWAS �S:Si#�;et�t "{FS fit#` ,€ria. t':P 352 <br /> ie�G t <br /> IC, A'HAZA I)OU:r>WA�T�;s€;uri,Af3S0R 31-- Trs.eft€. ;i i+ ru 35 <br /> 3. <br /> 4. <br /> f <br /> 14.Special Handling Instructions and Additional Information <br /> t. Fli 11At r�3s1` t ,c'il At 11_ ts3d ' tL kL 3 <br /> =stw '_ }�P�pa(�^ <br /> YaI�'Lw <br /> j,, j ^qy CYC $ -r^ j�+y}[{,� <br /> 3.�n Y`i 8'd'YJ S Ras �l'; 6 3ls td�N <br /> 15. GENERATOR S/OFFERORS 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national mmental regulations.If export shipment and i am the Primary <br /> Exporter,i certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm5pt-bi 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) I I am a smatl.gji&`ntity generator}is true. <br /> Generator"st ffe is Pnnam,.r' <br /> tedrryped Ne Sinatur' 9 � Month Day Year <br /> r A d <br /> a 16.International Shipments <br /> F- ❑import fg't�.i Q Export from U.S. Port of entryfexi'0 <br /> ? Transporter signature(for exports only): Date leavirT,U:S.: <br /> Ce 17.Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> Tr rls pffer i Print e yped Name Sigpature, y Month Day Ygar <br /> �J" r..a`i *� 4. % �� _ ' f.':+¢,.r 5..r.2..,,✓:%°' 'w.' l of <br /> Z Transporter2 rintedrfyped Name Signatgte *: Month Day Year <br /> 101 <br /> 18.Discrepancy <br /> d" <br /> 18a.Discrepancy Indication Space ` <br /> ❑ Quantity Q Type Q P,esidue Partial Rejection Full Rejection ' <br /> JZ 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> uUit 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal and recycling systems} <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item)Iqtr r <br /> Printed ype Name Signature r Month Day Year <br /> EPA Form 700-22(Rev.) 17 Previous edit ons are o6sofete.` r� DESIGNATED FACT(ITY T,O GENERATOR <br />