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n <br />y 9b <br />Please Ddnt or tvoe <br />Form Approved, OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />�1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />013120686 FLE <br />WASTE MANIFEST <br />: �, , -I(ATI)577--'F <br />F, <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than maiting address) <br />Famiy Dollar # 31867 Family Dollar#31867 <br />(209) 924-4046 2350 G. Airport Way 2350 S. Airport Way <br />Generator's Phone: c" <br />6. Transporter 1 Company Name . Ea Number <br />I" <br />7.Transporterfftn,*G%b.ie Speciatity Weete GoliAteng Ilia um r <br />Systems 9422 <br />ftevery <br />8. Designated iMft e umber <br />Yuma fess LLC <br />2730 E. 13th Street <br />Yr-tma, AZ 85365 <br />Facility's Phon :,� <br />ga. 9b. U.S. DOT Description (incl6409 --uding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wtivol. <br />ix <br />ort RCRA hazardous waste, liquid (surfactants) <br />1 <br />F <br />0012187 <br />P <br />3:31 <br />z <br />2. <br />W <br />C7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1.10 3661 (CA State Regulated Liquids (L 0 0 s e p ac k) ) <br />SJ <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fugy and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and tabeledlplacarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. it export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of 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) (ifI am a small quantity generator) is true. <br />7enetoesiofieroes Printed Name G si not , Month Day Year <br />W,4Wmig <br />F <br />nternational Shipments <br />F1t S. ❑ Exportfrom Portof a lexil: <br />z <br />.S. <br />ZsportersIgnature(for exports only): Date le 'ng U.S.: <br />W <br />17. TransporterAclmowWgment of R ipt of Materials <br />Transporter 1 PrintedlTyped NameS' re <br />Month Day Year <br />O <br />q-onv <br />c <br />ransporte n am S' Mon Day Year <br />Za 22 <br />18. Discrep <br />18a. D' nay Indiction Space ❑ Quantity ❑ Type Residuei <br />❑ Partial Re ect on El FUII Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />FacilitysPhone: <br />w <br />180. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as now in Item 18a <br />PrintedlTyped Name Signature <br />Month Day Year <br />EPA Form 870-22 (Rev. 12-1Previous editions are obsolete. <br />_RAAKIICCQT QVQTr-M <br />