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Please print or type.(Form designed for use on elite(12-pitch)mxwriter Form <br /> Approved.OMB Nn.2050-0039 <br /> UNIFORM HAZARDOUS 1 GeneraW ID Number 2.Page 1 of 3 F.rnergency ftespow no ant rac ng Number <br /> WASTE MANIFEST ,AL000092"' 8 [4=329 JJK <br /> 5.Generalars Name and Mailing Address E rOy Generators Site W&M(d d fferent than mafling address) <br /> i <br /> M[RTC ; M 95923 -WFAM_NM 6 � <br /> Generators Phone: 4�3-AZT$ <br /> 8,Transporter 1 Company Name U.S.EPA 0 Number <br /> !RY U M MMIEtilTAL SERVICES 2 7 7 0 3 6 <br /> 7,Transporter 2 parry Name U.S.EPA ID Number <br /> 8.Designated Faca y Name and Site Address U.S.EPA ID Number <br /> JFiLL <br /> Aiii-0UL 34C GMNTY 12TH STREET <br /> 86356 AZR000002428 <br /> Facility'$Phone: 28)"r&S•3 f97 <br /> ga. 9b.U,S,DOT Description Including Proper Shipping Name,Hamrd Class,ID Number, 1e-Containers 11.Total 12.Unit <br /> HM and Padtirp Group(d erry)} 13.Waste CodesNo Type Quantity WLW <br /> 1. .._,2-RCRA 142j...__-JS WASTE.LIOLD(OILY WATER) D G 1 2� ' <br /> 3. <br /> 4 <br /> 1 1-4 <br /> 14.Special Hand.ng InshvcOm andAdditlonal Information <br /> ACT-GHEIATREC 1.80x424-8300 NAERGO £;1131.171 *PROFILE 0 981:OW-COPPER *EMERGENCY <br /> GOINTACT:CHEMYREC 1-800.42493DO *APPROPRIATE PERSONAL ROTECTIVE EQUIPMENT � O <br /> ZIP <br /> 15. GEHERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of phis consignmerd are fully and accruatey described above by the proper 4V name and are classified,packaged. <br /> maAad and habaledfplatxrded,and are in al respects in proper condition fortransport according to applicable Intemational and national governmental regulakm.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 EPAAcknowledgmant of Consent. <br /> certify that the waste aftnizalion statement identified in 40 CFR 282.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is two. <br /> GeneraterstMerors Printedlfyped Name Signature onthay Year <br /> J 16,international Shipments 4 �Y <br /> f ❑import to U.S ❑Export fmm U.S. Port of entry/exit <br /> z Transporter signature(tor exports only): Date leaving U.S.: <br /> 17.TrarsporterA MaMedgment of Receipt of Mateitals <br /> Trar4{ .er 1?rinte6Typed Name 5rgnature — gr Day <br /> I rarsporfor 2 f an%47ypad NameII <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18x,Discrepancy Indication Space ❑ Guonley ❑Type ❑Reskfue ❑Partlai Re)W, ❑FullRefection <br /> Manifest Reference Number. <br /> 18h,ARemale Facility(or Generator) U.S.EPA ID Number <br /> _t <br /> U <br /> ua- Facility's Phone: <br /> El 1 k igna(ure of Alternate Facility(or rahor) Month Day Year <br /> a <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes Ila,codes for hazardous waste treatment,disposal,end recydnig systems) <br /> o1 1 �"7 2. <br /> 20.Designated Facility Owner or Operator:CaWkipilim of receipt of hazardous matedale covered by the mangest except as ncled b Item 1&a <br /> Prinloarryped Name r Signature _ F Month Day Year} <br /> 'r_•✓,'V^%'7 '-✓f is iii % , <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />