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Please print oForm Approved. OMB No: 2050-0039 UNIFORMM HAZARDOUS ZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ; r;,U28s4a� 1 888-785-7225 01228336t7 FLE 5. Generators Name and (Nailing Address Generator's Site Address (if different man mailing address) pL L) 1 M0 McKinley AValtie <_heM, hethliir ernusa. com Lathrop, CA _^ GeneratorsPone : 8. Transporter 1 Company Name .4dvdnrr_ _ � '•,. ACTEt`1�✓113�% U.S. EPA ID Number CAf2p.X'1070546 7. Transporter 2 Company Name '✓Vp; - . ,_ ._ ; - U.S. EPA ID Number CAR00i e. Designated Facility Name and Site Address Yuma YES U.S. EPA ID Number 30 E' 27 . 13tLLC h St AZR000515924 Yumn, AZ 85365 Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (If any)) 10. Containers 11 . Total 12. Unit No. Type Quantity Wt./Vol. 13. Waste Codes 0 Tardous Waste Liquid (011, Water? DM P 2s W z 2. W 3. 4. 14. Special Handling Instructions and Additional Information Project Number 183120 I',r„c— 1171 CRY 15, GENERATOR'SIOFFEROR'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, marked and labeled/placarded, and are in all respects in propercondition fortransport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/ORerors Printed/Typed Name SignatureMonth Day Year � 16. International Shipments _ ❑ Import to U.S. LJ Export from U.S. Port of entry/exit 3 Transporter signature (for exports only): Date leaving U.S.: ILL! 17. TransporterAcknowledgment of Receipt of Materials Transporter 1 Print= i yped Name SignaWre a - 1;Z— S /'� _ / Month Day !Year �Transporter2 Printed/Typed Name Si gnature 9 month �Day Year r 18. Discrepancy 16a. Discrepancy Indication Space Quantity Type ❑ Residue ❑ Partlal Rejection ❑ Full Rejection 18b. Altemate Fading for Generator) Manifest Reference Number: U.S. EPA ID Number U LL Facility's Phone: w M. Signature or Anamate Facrity (cr Generator) Q Month Day Year z w19. Hazardous Waste Report Management Method Codes (i.e., codes forhazartlous waste treatment, disposal, and recycling systems) D 1 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnnted/Typed Name Signature Month Day Year EPA Form 870022 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY