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FFB 2 7 2017 <br />rlease print a type. (Form designed for use on elite (12 -pitch) typewrfler.) rune r+pyiuveu. ���o r.�. <�.n,„�„� <br />EPA Form t1lUU-YZ ( <br />UNIFORM HAZARDOUS 1, Generator 10 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest TracNumber <br />1087 G B F <br />lJ U ; <br />WASTE MANIFESTial ,1 <br />5, Generator's Name and A1atIN Address Generator's Site Address (d different than maAing address) <br />ib'tftt'I{A IIHk REPAIR <br />I.d11 N: 0I Kill F.11 WAY <br />Generator'sPhone:;- -pit <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />AFAGRICAN VALLEY WAUIF OIL. IDX;. CAI 0FW4 ItliH <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />*081 1 )WH J, IfFCOVIF'Ry SYSIFFULS 1W <br />8. Designaledl FadLty Name and Sae Address U.S. EPA ID Number <br />ftAtA Ytzli LLC n„'t'n1111 , . <br />YI311F I:STtib, <br />Facili 's Phone: t.7! of? 4VI ul <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit 13, Waste Codes <br />HM and Pacldng Group (11 any)) No. Type Quantity WW(A, <br />1' IN-)NA%1iIlA14AZARtKA)SWASfE SOLID <br />'to <br />!' <br />_ <br />i Ci Vi:B PAPLIi 011. 1 WI0:; R lkbttlli <br />z <br />2. <br />w <br />c!) <br />3. <br />4. <br />14. Special Handling InsWcbons andAdd tonal Information <br />t'ttc4-lLEa IW32VNKF 3 PAPC.RFILY11Ht; HN(0 1; 1 <br />10{i%1FN(;Y('('NI'ACA r,A.SVIR <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consgnmant are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlp!ararded, and are in all respects N proper condition for transport a000rding to applicable International and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I cerUN that the contents of this consignment conform to the terms of the attached FPAAcknowledgmenl of Consent. <br />I cedfy that the waste maim'¢ation datemenl identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (61 am a small quantity generator) is true <br />GeneraWsl01femrs Pdnled7Typed Name Signature Month Day Year <br />� <br />16. International Sh!pments <br />1:1 Import toU.S, ❑Fxportfrom U.S . Fort olentrylexil: <br />2 <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17.TranspodarAckwMedgmentafReccVofMatoais <br />r <br />Transporter 1 Pnnted(Typed Name Signature 6117th Day Year <br />z <br />Transporter Pdntedffyped Name Signalure Month Day Year <br />Q <br />18. Discrepancy <br />18a, Discrepancy Indication Space ❑ Quantity El Type ❑ Residue ❑ Partial Rejectron ❑ Full Rejection <br />I Manifest Reference Number. <br />181h. A1temate Fadlity (or Generator) U.S. EPA ID Number <br />J <br />U <br />tai <br />Facilrys Phone: <br />Month Day Year <br />U <br />18c. Signature ofAnernate Facirity(or Generalor) <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyOng systems) <br />UJ <br />1. 2- 31 Notice: State of California requires <br />generator to photocopy and mail to DTSC <br />20. Designated FaabtyOwner or Operator. CenlAcatlon of receipt of hazardous materials covered by the manifest except as noted in Item 18a within 30 days: <br />PrinledlTypedName PP, Signature P.0 Box 400, Sacramento,CA 95812-0400 <br />K2V. J -UJ) YreVlouS eumais me uwurme. <br />GENERATOR'S INITIAL COPY <br />