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Please print or type,(Floxim designed for use on elite(12-pitch)typewriter) Form Approved,OMB No,2050-0039
<br /> UNIFORM HAZARDOUS
<br /> OUS I Generator ONUMbr 2.Page t of 3.Emergency Raspense Phone—--I
<br /> Manifest
<br /> anifest Tracking N9m2bjr
<br /> WASTE MANIFEST AL000379505 69
<br /> FLE5,Generator's Nameand
<br /> Marling Address eratoes it aAddr9ssffciferanfthan mailing rens) 1
<br /> —
<br /> Smart & Final #403 Smart & Final#403
<br /> W4643829 147 N. Wilson Way 147 N. Wilson Way
<br /> Generators Phone: c'
<br /> qfnru4,nn_ ra
<br /> 6.T(ansporter 17cmpany 9521715 1
<br /> .1tackto t;S.
<br /> Nombar
<br /> 7 Transporter Rfa"Pvy Nmc Epp-iAlfu wag
<br /> U.S.EPA 10 Nume
<br /> Worldwide Recoyery Systems
<br /> _8Des FaedFac JIJtvN8rn)eandSdeAddresg ICAR000175422
<br /> Yuma Yes, LLC US EPA ID Number
<br /> 2730 E. 13th Street
<br /> Yuma, AZ 85365
<br /> Facifil
<br /> A7PLOO515924
<br /> ga 9b,U.S,DOT Description(itiomcir.) r;!ass,
<br /> HM and Packing Group(if any) 11)C�)ntaioeri, 13"Nastecodes
<br /> No, Typt,
<br /> Ion RCRA hazardous waste, solid (Consumer 1 F 0013-2 T_ 331
<br /> products),
<br /> re
<br /> LU
<br /> Z
<br /> don RCRA hazardous waste, liquid (ConsUffler 1 )F 00 147 7
<br /> Droducts), 331
<br /> 14 Spacial Handtlng Instructions and Arfdifional Information
<br /> Liquids —CA) 1- 101321 (State Regulated Solids CA) 2101320(State Regulated
<br /> wo
<br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurate;y described above by;,a,)toper shioping name,and are classified,paiAagea,
<br /> marked and labeledoacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I art,the primary
<br /> Exporter,I car*that the contents of this consignment conform to the term of the attached EPA Acknowledgment of Consent
<br /> I certify that the waste minim zatior,statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> GerieratoestD!Ieros Proted/Typed arae Varith----77E"ar
<br /> alf.1—of-79mart".14, 0iinal
<br /> Import to,I, 7-1 Export from U.S. Port of entrylexit fA I A
<br /> -Transporter S$22atura(!2r ex s only): "IM.
<br /> 17.Transporter Acknowledgment of Receipt of Wtenas
<br /> Transporter I PrintedlTyped Name
<br /> 5iginature ----------
<br /> 0 th l5ey Year
<br /> 0. <ristoDher Alman7a
<br /> tt PrintedfTy Name ------
<br /> Z Tran gneth
<br /> 18,Discrepancy
<br /> 'IIar Discrepancy Inoicohor,Scace
<br /> F79uanttEy , R,,,,., 131"ailialRele0"It" El Full Rejection
<br /> ity nor Gcntyator�
<br /> 18b.Alternate FarTManifest Relerev,;,Nurnoar: U.S.EPA ID
<br /> V itys Phoin
<br /> U"j 1`74wsture Piro,:
<br /> Poternate Facility(or Generator)
<br /> I— Month Day Year
<br /> 19 HazardoutiWasle Report Maragementmeth
<br /> od Codes, ides'or hazardous waste treatment,disposai,and recycling systems)
<br /> 20 Designated Far.tity Owner or Operas ',er:Ircatior,of receipt of hazardous ir=ajepals cover, cv! a.�ifest ex as
<br /> PrmwypajNte - �d rie m
<br /> Siprature A
<br /> Mont h Day Year
<br /> ItAl 112- 1
<br /> 'PA Form 8700-22(Rev,3-05) Previous editions are obsolete.
<br /> I 1 -1 XATE FAOILITYTODr:$TINAriON,5TAI-E-(IF REQUIRI-D)
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