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M <br /> m <br /> CD Z' <br /> CD I O N O <br /> o 0 ri <br /> - o C) <br /> N A CD D <br /> o CD m <br /> M <br /> 0-00 <br /> Please print or ,type, Form Approved.OMB No.20539 '�F r— <br /> = ffUNIFORR.AlHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Maannifeest Tracking Nummbberr Q p ��' O <br /> Cn ANIFEST OiJ1$$ FLE `D ° <br /> GAt.,-— 1 r t T'2.:Name and Mailing Address Generators Site Address(if different than mailing address)America i) famterly R3rH«}>WIW Rdl,CA 95205 CDhone:209-761�iFjOQ <br /> 6.Transporter 1 Company Name U.S.EPA ID Number 0 <br /> Ad1HnO0d r..htvntCat 1•ra ISPOA IInr,JDBA ACTenwu +;Eif?OOtX57u r+i <br /> 7.T,(ar��gooMrz Com�Q�aany Namef� tiyuCFJ111, U.S.EPA ID Number <br /> 4/ott T1t1e FCCC AF* 6• CARLN301`i sC2r O O <br /> 8.Designated Facility Name and Sile Address Z z <br /> EPA ID Number <br /> U.S. <br /> Yuma YES,LLC C7 <br /> Yuma Ara 53SS f�2 O'-yc�z4 �0 D <br /> FarC <br /> dtitys Phone: L'l&3L�a aui);+,7,y N (.0 <br /> CTI <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 13.Waste Codes 11.Total 12.Unit NO <br /> HM and Packing Group(d any)) <br /> No. Type Quantity WWoI. CrI <br /> tiVrrn•RCRA Hru snlous wewc!i iquid,(P-Vs Waslu-_rty� P 2?3 <br /> IF Solution) y <br /> CP <br /> f <br /> 3. ! CD <br /> i( N <br /> — O <br /> rn <br /> 14.Spa"Handling-and Additional Information _ _F'tn'oct Pl;�mt r �3D841 Cuculr, W&2-14W&2-14 �. <br /> CCD <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable inlemationaland 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quardly generator)or(b)(ill am a small quantity generator)is We. <br /> GeneretorslOBerors PrintedrTyped Name Signature Month gay Year <br /> \` x <br /> t� <br /> J 16.International Shipments <br /> F. ❑Import to U.S. ❑Export I.U.S. Port of entry/exit: _ <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TransporterMJmowiedgment of Receipt of Materials <br /> 7ranspo11er1 PrinteklR Name y,_. _ - Sgnature— j Mgnlh DqYear <br /> QC <br /> Transporter 2 PrintedrTyped Name Signatre <br /> K Month Day Vear <br /> 1— <br /> a. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quanti <br /> ry ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadtitys Phone: <br /> b 18c.Signature of Alternate Facility(or Generator) C!ontn Day near <br /> 1t1tt 2 <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O <br /> LU 1. 2. 3. 4_ <br /> 20.Designated Fadliry Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> + Printed/Typed Name <br /> Signature Monty Day YearC=C <br /> EPA Form 870O-22(Rev.12-17)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> N <br /> (Q sem ze.. ,•� <br /> (D <br /> A <br /> O <br /> A <br />