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14%011 0 '- Please print or type. Form Approved. OMB No. 2050.0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Erne ency Res nse Phone WASTE MANIFEST ° - r 4i Lir 9 2 G BF — .-- - - - -5:-Generator's Name-and Mailirrg-Address - - ----- --- - - - - --- -------GenprataY�Slt�Addrass-(N�1KferanCgtan-ma111m,FaUdrass) ------ ----- - _. .-- . -- 3%) KCK7LEY AVE Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number WIT F+ EINI OM .`$ESNTAL S .ERIVICNES , LLQ: A S D O B 1 7 0 5 ,S4 E STONEY FM COOLroGE ,, Az sins ; 1 C ) ? 23 �- 4167 Facilites Phone: 9a. 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Contalnare 11 . Total 12. Unit 13. Waste Codes HM and rPacking Group ('rfany)) �+ {y � ry� }y �yT 1 ��. ytt� 7 1 No. . Type Quantity WtJVol. C Arlin Wk,.+ /R FElF�/ ,4tC'4 . ED , WILY kt�-i.:3ril s' r 13J:r7�1J"1,0) l Ju z lam 2. W U' 3. 4. 14. Special Handling Instructions and Additional Information 2 ) CC 42?4Et40lltw4 T8084 V2, 12167� 1 Clart(ted to ;jhisl bV )� rmob, t canNits ojWm ' Gt#`,i7. ft an irb I b'9ropltv to rvJd or sdoilhi-Iik addlD 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 labeledtplacarded, 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 EPAAcknowledgment 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. GeneraloeafOfferoes PdntedfTyped Name Signature Month Day Year ck. e 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port ofentry/exit: Transporter signature (for exports only): Date leaving U.S.: W- 17. Transporter Acknowledgment of Receipt of Materials Trarte 1 Printedll' Name Signature Month Day Year O 9L to ran porter2Printe yped erne Signature Month Day Year I 9�1 2 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity El Type ❑ Re ue ❑ Partial Rejection F] Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number v LL Facilites Phone: 18c. Signature of Alternate Facility (or Generator) Month Day Year 4 z 19. Hazardous Waste Report Management 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 manIfesVxcqpt as noted in 18a ®rl e yped Name Sig y. Month DayYear av lip 5Z UaJ4 I -tz 8700-22 (Rev. 12-17) Previous editions are obsolete. DES GNATED FACILITY O EPA's e-MANIFEST SYSTEM