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Please print or type.(Farm designed for use on elite(1k, .,.n)i ttwriter Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone4.#antfest7rac Ing Number WASTE MANIFEST CA L 0 0 0 3 0 1 9 9 9 1 (800)424.9300 1 018529390 JJ K 5.Generewes Name and Moiling Address Generators Slte Address(If different than mailing address) CEMEX READYMIX-4461 2365 IRON POINT RD,SUITE 120 ATTN: ENVIRONMEN FOLSOM CA 95630 :30350 S.TRACY BL. GeneretsWa Phone: 209 993-74514 TRACY CA 95377 6-Transporter 1 Company Name U.S.EPA ID Numhnr . -""gRONMENTAL SERVICES e r 7 n g a 7 Transiwrref 2 Company Narn� :�, U,S,FIaA p].iVuingerY i EM 1114t f- C�1Ri}0A1754A..2 8.Desicgnalad Facility Naine and Slte Addressi U.S.EPA ID Number yUTs�il..it�l.l.lit:c....r_`.: - .'� �'. .. f�;.b�/1w•� •:� . 2730 E 13TH ST ___ YUMA AZ AZR000515924 Facillt es Phone: 's l^L ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group('d any)) No. Type Quantity Wt.Nol. � X52 g D M �� P �Z 2- w L7 3. 4. 14.Special Handling.Instructions and Additional Informetipn _ EC 1-800-424.9300 WOES TERMINAL: *PROFILE 0 9B1:162823 IRACFM605 OILY$DUD aoc r _ -<' � rel y J .t 15. GENERATOR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(if I am a smakquantity ggpKator)is true. Genoralor'8101ferofs Printadffyped Neme Signature Month Day Year 16.Intemafional Shipments ❑Import to U.S. F-1 Export from U Port of enfrylexit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1.Rfintedffyped tame t Signature McNh Day Year yi �� '/ ! 3 Transportar 2 PrintednWed Name 5ignalura. Month Day Year cw 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Fadilly(or Generator) 3.A .r•i• :U S+EPAitI-Hamper V . Faclllty's Phone: W 18c.Signature of Altemale Facility(or Generator) Month Dsy Year Q Z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P nted ypod Signature sar 1A-- EPA Form 8700-22(Rev.3.05) Previous ed tions are n -DESK6ATED FACILITY TO GENERATOR