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i <br /> please print or type , (Form doolgrtad for use on elite (12•pitcb) Iypow6tgt Farm Ap "ode OMB No. 200.0039 <br /> 1 Gexralcr ID �luL ' 2, Page 1 01 3. Enxrgapcy Resporrsa Phone 4, Manifest me ng um sr <br /> ""wasT� Ma AF sTu$ G A LO 0' 0 3 6 4 :� ( 800) 11124.9300 01, 8529431 JJK <br /> 6: G u 's ', qct o i d Generatdrs S!la Addross (If iffilatd than mailing address) <br /> 39 I���'1h��� �' E(�f� �'�r�vict <br /> (_001 CA 91 ! 2110 <br /> Gen Tatoes Phalle: 209 339*1916 <br /> g7.. TTrrapaeYVnd4k_ U,S. PAA IIDj NUum:b' o$r <br /> W6LDIr � RONh4ENTALSERVICE:i U.S. EPAIONumber <br /> EBWUVIiIVI! R%I YSI4ZM iN ^. <br /> GAR9001 "1 542. 2 <br /> 8. 0 . F4at,14bI aon, SiteAddress U.S, EPA IDNumber <br /> �tV1A Y15 L�� ' f <br /> 1. 730 E ls1rli 31 <br /> Feci° YUMA AZ 8535 AZRtOOOB15924 <br /> tys Phone, (928)M+98423 <br /> 9a, ? I gboloolS DOT Descrip'ron gn.dud[ny Proper Shioptng Name, Hazwd Class, ID Number, 10, Conialners ii , Total 12. Unit 134 West$ Codes <br /> Hldl and Packing Group lit any)) No. Type Quantity wtNi to <br /> dominion 1NpN RGRA HA?ARDOLf ; WASTE , oSOLIU ( �IILY SOL10 , PAPER F1LTERSj 3r�? <br /> LU <br /> 2. <br /> Utz I V 1= LOJ <br /> Motion <br /> MAY 2 2 Z515 <br /> - <br /> ' 4 HUMP <br /> DEPARTMENT _ Q <br /> td. Specaf Handling Insltuctons 6mlAdditional Information <br /> IsiliE€)GENGY CONTACT : CH19 M ' RK :i.-800-cl24� 9:)00 Vd01:S IOE.RMI (JAL: * PROFILE: # 9r:L : 16l623NR!3BAN043 OILY Sf)L) D3 j <br /> )JAPER FILIi 134; a' ;ki APPROPRIATE PPE tt) 111P )vl £ NT p07 <br /> L0000 <br /> 14, GENERATOWS[OFFEROR'S CERTIFICATION: I hereby declare that the contero of this consignment am fulyand acsutata ydesclibed aboys by the prop6( shipping r+ama, and are classfed,packaged, <br /> onrsed W labofodrplowrdaf..end are A a1! respects In propoi condlion for transport weeding to apOeaVa intatnabgnnl nM national govornmontal regu%Nns. II eliport ehlpirant and I am ilio Primary <br /> 0potter, I Certify eutt the w.tana of KN toilLsigroviont conform to the torms of the attached EPAAdmowiodamoni of Consent <br /> j l conify Out Ow waste min mrzaton statement ldenG6ed In 40 CFR 26227(x) (if 1 am a largo quaintly Igenerator) or (b) (!(I am a smell quordg}' generator) Is Kit <br /> *net. Ili tars Fr rded?yped Nnrne Sion uta / Flanfh Day ear <br /> � 16, Irdematiorai 'prneras n <br /> Fitton, 1 ` _ Irnoo t to U:S. ❑ Expw from tV Pun of anhyfeAt: <br /> Z itansporler srgnatuta Ikr axfwrts GnY1; Hata leasing U.S.: <br /> � 17. Trar>SpotlerAL~cna»1MgmantotRaxlptoFllaletiels <br /> Trarspone d •edTyped ame SgnaPtfo Month Day �ar _ <br /> a �JwL11q <br /> ❑/// j'/(1 <br /> T n Gnnar 2 pr ni ib ypnd ame p Signature NbnOt Day Year <br /> �Ar <br /> 18. D.ettkpan�y <br /> Iia. Alst opsnsy Indication $Paco ❑ LJ Ty .oe El Residue El Partial Rejection El Full Relecllon Quaintly ; <br /> Manifest Rolererce Number: _ <br /> f 6ti;Me"ale FacIty (orGenwator) U,S. EPA ID Nvmbet <br /> U <br /> W Farlty'sPhone: <br /> 8r.; & rgr'nluro of Memo Fab!1y (Or Gonomlot) IlOnth Day Yea <br /> 19 <br /> z <br /> 19, Hazardous Waste Report Management MOW Codes (i, e. , codes for hazardous wasm troalmont, disposal, ani recycling sysiemsl <br /> d, <br /> I �6 <br /> 20. pesigneted Fab ity Oanar or Oporafoc Cadi�iCafron of reu,pl of hazardous maloriais covelred by the rnan�esl axCopl ns c In ham 18a <br /> PrintecllTyped Signature Year <br /> JO �A A I "i Ir <br /> ID <br /> EPAFoim 8700. 2 (Rev, 3.05) Pie9lous etlltions ra obsolete, mlal� �rnu OAcu .rl'Y 1' U)= " 'INAI'i0N 5'iar, (IF REQUtmam ) <br />