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- .` RECEIVED BY SJC EHD ON 7/3/2019 <br /> Please print or type. _ <br /> 1 Generator IDumbe14.ManfttT'ldr`g Form Approved.OMB No 205G-0039 <br /> UNIFORM HAZARDOUS � hone m <br /> WASTE MANIFEST CALS21206M 7e 012860822 FLE <br /> 5.Generators Name and Mang Address Generators Site Address(it different than marling address) <br /> S MOM l Utes APR 19 2019 <br /> 10 CA 9 A►�. �n� <br /> 0130 <br /> Genera - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Adwrced C hemmed TrwsPtrt Ii c.IDBA ACTEWIRO CAROO=0540 <br /> 7 harsperler 2 C�� r U.S.EPA ID Number <br /> +` CARDt70'1754M <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> YumaYEZ730 E. 1�St A2RO00515824 <br /> Yf lfnA AZ 85355 <br /> Fadli s Phone 92B%3444NM <br /> ga. 9b U.S DOT Desarp m(including Proper SNppmg Name,Herd Class,ID Number, 10 Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wt1Val. <br /> 1 NDWRCRA Haaardow Waste Solid(Oily SaUs) OM r� P � <br /> o � If <br /> 1 1 <br /> � 2 <br /> W <br /> c� <br /> 4 <br /> 14 Special Handling Instructions and Additional In tion PMOONumber 196M >DOCmcod t M34443 <br /> 1) 1741379 SUY- 1 Xf�:Sv(`^ <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aoarralely desaibed above by the proper shipping me,aril are classified packaged, <br /> marked and labaledlplacarded.and are in all respecls in Proper condition for transport according to applicable inlemationaland national governmental regulations.0 export shipment and t am the Primary <br /> Exporter,I certify that the contents of the consignment conform to the terms of the attached EPAAdknowledgment of C insent- <br /> I certify that the waste minimization statement identified in 40 CFR 282.21(a);d I am a large quantify generator)or(b)(if I am a small quantity,generator)is true. <br /> Generator arar'a PrintedIT Name ? / Signature Month Day Year <br /> �d any <br /> J 15 International Shipments <br /> ❑Import to U.S. ❑Export from U.S Port of entry/em <br /> Transporter signature(for exports orgy) Date leaving U.S <br /> M 0 TransporterAd nowledgment of Remo of Materials <br /> Transpo4or 1 F-wWTyped Name Signa Year <br /> Name Signahrre Mordh Day Year <br /> IPA ) il <br /> 18 Discrepancy <br /> 18a.Discrepancy.ndication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fa Rejection <br /> Manifest Reference Number. <br /> 186 ANemate Facility(or Generator) U S.EPA ID Number <br /> J_ <br /> V <br /> ra+- Fadlity's Phone' <br /> T Signature of Alternate Facil-ty,(or Genemlor) Month y Year <br /> FIR <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> O 1 2 3. T4. <br /> 20 Designated Facility Owner or Operator Ceff ation of receipt of hazardous materials covered by the manifest except as in Item 18a <br /> Pnrred+Typed Name Signature r Maf+tt} Yeah <br /> ic{ I�� Vi I I.Ii i G1 (fr <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATEDFACILITYTOGENERATOR <br /> f <br />