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Please print or type-(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1 Genemlor ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST I JJ K 5 Gun eratrV9 Name.and Mallirig Address Generators Slte Address(if diflerant than mailing address) Generator's Phone: 6.Transporter 7 Company Name U.S.EPA 0 Number T Transparter2 Cnrnpany Name U-S.EPA ID NurrOor ;r: CAC 42.- 8 Deslgna[ed Fgpilily Name and Site Address U.S.EPA ID Number YGiva Trac, F"ac i h50.) 5 US taighdsq 95 , Yum--% , Ariz►, Facllity'sPhone: 928-344-9U8 A,7R Duo 521 1 r,;; ga. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10 Containers 11 Total 12-Unit HM and Packing Group(if any)) 13-Waste Codes No Type Quantity Wt.Nol- f o NON—RC PA HAZA3tTVN1S WA5t - S rLI ',;S - � z:{'ilg SoZi1i_ z 2 w 0 3 d 14.Special Handling Inshir;l ons and Additional rnfrlrmalion. . f A l?;FTJ ANI. LI` F P., 15 GENERATOR'S/OFFEROR'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, marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true Generators/Offeror's Printed/Typed Name Signature Monlh Day Year J 16.international Shlprnenta z ❑.Import to U S. ❑Export from U-S Port of entry/exit: Transporter slgnatura(for exports only): Date leaving U,S,; UJ 17 Transporter Acknowledgment of Receipt of Materials W Transporter 1 Prinled1Typad'NMa' Signalure Mpnlh Day Year a- `'. �rilandeZ zQ Transportar2 Printedrfyped Name Signature Mpnlh Day Year F 18-Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S-EPA ID Number J U LL Facility's Phone: w 18c.Signature ol'Xietrato Facility(or Generator) Month Day Year Q Z C9 LU 19,Hazardous Waste Report Mpnagamenl Method Codes(i.e-,codes for hazardous waste treatment,disposal,and recycling systems) 0 1• 2. 3 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name 549nalure Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY