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Form Approved.OM No.2050-0039 <br /> Please print or type- <br /> 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 ManifestTracking Number <br /> UNIFORM MANIFRR <br /> EDD <br /> ST I-SM-785-7225 p 12 2 8 5112 FLE <br /> WASTE MANIFEST CRLt� 028$48 <br /> 5.Generators Name ar.d Mailing Address Generator's Site Address(if different than mailing address) <br /> ❑fel on ESP LTD <br /> 1570 MCKInIe Aenue Sherri.hethea@rnodernusa.Cetyl <br /> Lathrop, CA 95330 <br /> Generator's Phr:ne: 209-858-9125 U.S-EPA ID Number <br /> 6.Tr nsporter 1 m any Name CAR000070540 <br /> Advance�G�hefmical Transport Inc./DBA ACTT=NVIRO <br /> U.S.EPA ID Number CARD00175422 <br /> 'l 0 d'*2cfe`ge6Noveery System, Inc <br /> U.S.EPA ID Number <br /> 8-Designated Facility Name and Site Address <br /> Yuma YES, LLC AZROW515924 <br /> 2730 E, 13th 5t <br /> Y u ma, AZ 8535.5 <br /> Fagility's Phone: 928-344-9828 <br /> to Containers 11. n ty 12-Unit 33•Waste Codes <br /> ya 9b.U.S-DOT Description[including Proper Shipping Rams,Hazard Class,il}Nwnber, No Type Quantity WtBoi. <br /> �{ and Packing Group li;anyjj <br /> 1 ❑n azar nus aste Liqui i, Ater 223 <br /> 0 12 2S <br /> a <br /> L <br /> 2. <br /> La <br /> 0 <br /> 3. r?._ <br /> P14,8pe-,d1a1HandIhg <br /> - <br /> nsinaclons and Additional IrrformaGan F'li 01 ad Number 171512 Dactament#. C}2�033 <br /> 1 1811702 DRY-�� I2 <br /> W6 � fp <br /> 15. GENERATOR'SfOFFEROR'5 CERTIFICATION: I hereby declare that the conl!Ms of INS consignment are fully llnte n accula andy described national governmentalebyteguatn shipow expert name,and are <br /> classified,ama Primary <br /> d <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to app <br /> Exporter,I certify thal the contents of this consignment oonform to the€arms of the attached EPAAcknowledgment of Consent. <br /> I Certify that the wamo mini ization statement identified in 40 CfR 262.27(a)(if I am a large quantity generator)or(b)(ifi am a mall quantity generator)is true. <br /> Signature Month Day Year <br /> Generatodslafferor's rinted�fyped Nam <br /> A S I/ <br /> t6.Intemational.Shipments ❑Import to U.S. ❑Export from U. Port of an xlt: <br /> r~ Date leaving U.S.: <br /> Transporter signature(for e)po-ts only,, <br /> S7-Transperter Acknowledgment of Receipt of Materials Manl Day Year <br /> Signature <br /> � Transporter?Pnnted,Typed Name710 <br /> Tr ` <br /> O <br /> yy fonth Day Year <br /> x rangy porter 2 rinted+Typed IN gn u <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> ❑ Quartity <br /> Manifest Rererence Numoer <br /> U.S-EPA ID Number <br /> i8b.Alternate Facility(or Generalorj <br /> U <br /> rat Facility's Phone. Month Day Year <br /> U@ 18c.Signature of Alternate f=acility(or Generator] <br /> a <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,Wdes for hazardous waste treatment.disposal,and recycling systems) <br /> UJ <br /> l � � 3 4. <br /> 20.Designated Facility Owner or Qpetator.CerZcation of receipt of hazardous materials covered by the manifest except as net d in Item t8a Mon Da ear <br /> Pi JT d Name & Sr <br /> EPA Fo 8700.22(Rev.12-17) Previous editions are obsolete. IDE5IGNATE!}FACILITY TO PA'S e-IViA EST SYSTEM <br />