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Please print or type. Farm Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2-Page 1 of 3.Emergency Response Phone <br /> WASTE MANIFEST "AL[�f,If.1-16iiffdtr2 !l.l4s g4.ti-:1ti,;:; 11"UM"51758 <br /> G BF <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> PkSOCIAIED 1KAGIUK vii-00-€A <br /> ?A N. VO4T'URA IRD <br /> Generators Phone;.., I{ X I QN.CA 9tii4# <br /> 6.Transporter 1 MradwallU.S.EPA ID Number <br /> A€.t.RjC.AN VALLEY�iSTE OR- 04'x; 'i:.Ai;t3Q0212-Kr2. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> +ri+;ici.�)YVA&it Lwy L HY-1hay €?t .I <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> YUMA Ykb 21li-1t. f1IANSI-EN f XALfTr <br /> Facility's Phone:o 'A <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(f any)) 13.Waste Codes <br /> No. Type Quantity W1.Nol. <br /> 1. <br /> rY <br /> O 1+'W-RC`.RA ffAZAf2000i WASTIF I il(.M1ff}, 17fF,%H F1 IFI.,0111 <br /> uu <br /> Z <br /> 2" <br /> LD <br /> 3 <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> i'I 01-li 01E,113EL Uit. f:Ftt39 <br /> t,ME�R-.GWGY tt;(WTAC f CARRY <br /> 15. GENERATOR'SfOFFEROR'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, <br /> marked and labeledlplacarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262;271(if t am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferors Printed(ryped Name Signature Man f Day_ Year <br /> ,j 16.Intemational Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexii: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 panteryped Name <br /> r� Signature Month Dox Ygar <br /> ZTransporte72PnntedlTy0e Na"e Signature Mdhth ay Yeai } <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest <br /> 18b.Alternate Facility(or Generator) Reference Number: U.S.EPA ID Number <br /> J ' <br /> U <br /> if f=acility's Phone: <br /> El 18c.Signature oFAltemate Facility(or Generator} Month Day Year <br /> a <br /> z � � <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 0 1 2. 3. <br /> Notice: State of Californiamto <br /> generator to photocopy <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a with 30 days <br /> PrintedlTyped Name Signature DTSC W <br /> P.O Box 400 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. Sacramento,CA 95Bi7-0400 I <br /> GENERATOR'S INITIAL COPY <br />