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Please print or type.(Form designed for use on efte(12-pitch)typewriter) Fan Approwd_OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator fD Number 2.rage 1 of 3.Em9rgency Response Phena 4.14 a test T"'T-31251 <br /> aeltirt umbar <br /> WASTEMANIFEST U A L O D U 0:p,2 8 7 3 1 (8001424.9:i00 � s )� Nu L 5 JJK <br /> 5 Gorterto'a Name and dlarlingAddress Generator's SHeAddress d dti<crenl gran ma <br /> Irll 'IC114 t MEM r:,�ii;r<5h1i Nltrj f dingaddress) <br /> 1.510 F'C. !k m) 75'20 8 7524 P.FFgF P <br /> ar'.t;RAMEN'fu 'CSI 95820 SA'rFAMEfdTO CA 9582E <br /> Generaror+s Phono: 916 425•317 9 <br /> B.Transporter 1 CampaityNamo U S.EPA1Dumber <br /> N <br /> ASbUKY f_I,IVIRUNMU9IAL SEHViCE9 C A ID N 2 er Z 7 7 0 3 6 <br /> 7.Transponcr 2 CompanyNams U.S.EPA ID Number <br /> 8.Deslgnalsd FadTr y Name and Sue Address U.S.EPA tD Number <br /> COPPER MOUNTAIN LANDFILL <br /> AVENUE.34E,COUNTY 12TH SWET <br /> WEL-11YR AZ 8:13&6 p7RODDD02428 <br /> Facm sPhone: (928)785.3797 <br /> ga. 9b.U.S.DOT Description(mdudfng Proper ShlppbV Name,Hazard Class,ID Number, 10.Containers <br /> HM and Pac"Group pf any)) 11.Total 12 Unif 13.Waste Codes <br /> No. Type Quantity WWW. <br /> 0 1' NON-RCRA FLAZARDOUS WASTE.LIQUID(OILY WATER) <br /> 001 T T G ?:2 <br /> � 2, <br /> u I <br /> 4. f <br /> 14.Spednt Hanorg Insuucum andAddHlmat rnkmtatim f { <br /> EMERGENCY CONTACT f:HEMTREC 1-800.4249300 NAERG#i 981 :171 -PROFILE#I 901 ,OW-COPPER *EMERGENCY <br /> CONIACP CHEMT REC 1-8004249300 *ADDITIONAL EPA CODES. 9BI : .NONE "APPROPRIATE PERSONAL PROTECTIVE <br /> FQUIPMENI <br /> 15. GENERAT0RYif0FMoR'S CERTIFICATION: I hare <br /> we tat the oonlenls ortNisconslgnmentara to and arxrrrdlel dsscnbed above b !ho <br /> marked end Wmjodfptararded,and ace Ina mspocla In OWporid kn fortrenspod m=l b Y Y proper s.if ng name,and era t3I am amPackaged, <br /> Exporter.Ice*that the contents or Huls e� appbcalxe Tent of Con t and natranel goveunmeribrl regulatlorrs.Hoxpod shipment and I am tiro Pdmary <br /> +xarsignmeftl wnionn m the terms d the attached EPAAdmmsiedgrtrent of Consent. <br /> f C&*that Ihs waste mlr Mtml on statement IdantRed In 40 CFR 26Y.27(a)(d I am a largo quan5ty generator)or(b)(df am a small quantity generabr►is true. <br /> 4crammrw <br /> erreratorvufferors PMtogry'D4d Name SiQnatwe' <br /> Manlh Day Year <br /> ince datwrwl Shipments <br /> ❑Import to U.S. ❑epmt Irm U.S. Port of enwe d: <br /> sOuturee(far errporls ow: Date leaving US. <br /> 17 TransperlerAdmowledgrrod of Receipt or Matadais <br /> Ce G Transporter 1 Printedffyped Name ) Siglralum : I Month Day Year <br /> r f rr'r, � !•.' f r..L � 1 .i It L'/ �' l.' l 1 <br /> Transporter 2 Prertodffyped Name <br /> 5ignalure Morulh Day Year <br /> 18.Discrepancy <br /> 191.Discrepancy Irrdkafian Space ou'uH ElType ❑Residue <br /> ❑Partial Re)ecf.n Cl FUN ReJectien <br /> 1 Bb.Alternate Fachy(or Generator) AtarrHesl Referaoce Namber. <br /> U.S.EPA ID f4Casrber <br /> U <br /> FadHy's Phone: <br /> � 189-Signaaua of A4a=le Faeitty(or Generator) <br /> 2 Month Day Year <br /> 19.liaz utim Wasts Report Management.Methed Codes p e.,codes for trazacdmm wasle treatment,diwal,and recyding systems) <br /> 1. <br /> a l ) •,� ) 2 3. 4. <br /> 20.Designated Fadfdy Owner or Operelor:CeacaEon Or receipt of hazardous matelots coveted by the manifest except as ruled in Hem 1 Ba <br /> Prin[sdffypedNarrrc " <br /> lure ' � f M,rnlh Day Year <br /> EPA Form 87M22(Rev.3-05) Previous edi@ons aro <br /> obsolete. <br /> TRANSPORTER'S COPY <br />