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Ploaso print or typo . Farrn Approved . OMB No . 2050- 0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2 . Page 1 of 3 . Ema en ReG nse Phone 4 . Manite� t �t� �u <br /> WASTE MANIFEST cALQ0040ie5s { B�'17�) �� 7 - go Q FLE <br /> 5 . Generators Name and Mailing Addr ss Gene ators Site Address ( ii different than mailing address ) <br /> Marshalls # M0381 Marshalls # M0381 <br /> { 209 } 369 - 0992 2429 West Kettleoen Lane 1429 West 1e111e ® en Lane <br /> Generator' s Phone : Lodi , CA 95242 Lodi , CA 95242 <br /> 6 . Transporter 1 Company Name U . S . EPA ID Numbor <br /> Stericycle Specialty Waste Salutions inc M [V5000110924 t <br /> 7 . Transponar 2 Company Namer U . S . EPA Ip Number <br /> 8 . Uesignaled Facility Name and Sile Address Y U @d Yes , LLC U . S . EPA Ip Numtwr <br /> 2730 1 . 13th Street <br /> Yuna , AZ 85365 <br /> NI <br /> Facoity ' s Phone : 9286428938 AZ8000515924 <br /> ga . 9b . US DOT 0oscriptbn (induding Proper Shipping Nama , Hazard Gass , IQ Number, 10 . Containers 11 . Total 12 . UnR <br /> HI,, and Packing Group { d anyp 13 . Waste Cases <br /> No . Typo Quantity WLNoI , <br /> � t Nan RCRA hazardous waste , solid ( Consumer 3 DF 0024 P 3 1 <br /> Products ) , <br /> w <br /> � z . on R azar ous was e , aqui onsuver <br /> � Products ) , <br /> 3 . <br /> 4 . <br /> 14 . Spedal Handling Instructions and Additional Information A S at a Regulated Solids ) C . 102338 ( CA State R e g u l at e <br /> Liquids ) <br /> 15 . GENERATQR 'SIQFFEROR ' S CERTIFICATIQN : Thereby declare that the contents o ( this wnsignment are fully and accurately described above the r � �G( <br /> try p oiler shipping name , and are classified , packaged , <br /> marked and labeled/plarardc'd , artd are in all respects in proper condition for transport acrnrding to applicable international and national governmental regulations . It export shipment and I am the Primary <br /> Exporter, I certify that tho contonts of Uas consignmont conform to the terms of the attached EPA Ackrw,vtedgment of Consent <br /> I cenity that the waste minimization statement identified in d0 CFR 262 . 27( a ) ( d I am a largo quantity genoreta) or ( b) (if m a small quan ' ty generator) Ls true . <br /> Gonarator' ror's Printad/Ty amo Signature e a 0 ldonth Day Yaar <br /> ,� tB . IntemationalShip sols <br /> mport to U . S . ❑ Export from U . S . Po of en 'uyiexiC <br /> Transporter sgnature ( for exports only) : Date leaving U . S . : <br /> W 17 . TransparterAcknowa: dgmenloFRacciptotAla:�rials <br /> t-" Transporter 1 Printodffyped Name Signature Month Day Year <br /> 3ohnny Harper 1 3 20 5 <br /> Transpo 2 Prinled �yped Name � / �� � / yt S: gna Month payy fear <br /> t8 . iscrepancy <br /> 18a . Qisaepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejeclion ❑ Full Rejection <br /> Manitesl Raterence Number: <br /> 18b . A) temate Facility (cr Generator} U . S . EPA ID Number <br /> J <br /> U <br /> cQi Facilitys Phorm : <br /> � 18c . Signature alAftemato Facility (or Generator) Month Day Year <br /> a <br /> z <br /> 19 . Hazardous Waste Report htanagomen ! tdethod Codes {i . o . , codon for hazardous waste Ueatmsnt , dispose , and recycling systems ) <br /> 20 . Designated Fadlity Avner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name � Signature Month pay Year <br /> EPA Form 8700- 22 ( Rev . 12 - 17 } revious editions are obsolete . ``• 51 � �1A7 'eCIUTY TO EAA ' s e - fl1ANlFcST SYST ✓~ fa <br /> A7fhfil _ a9 1 ;a . , � r' 01 4Qi0yAlA 1 ^� i G` 4t71A '� 4C, Octh f141 �'-, 7GAGQ M bot t71 � 1 1 Q Rn1 rl '21 1 Q <br />