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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 10l 3.Emergency Response Phone 4.Man'est Tra i N m <br /> WASTE MANIFEST LA1'0#72": }U3>� u �r- X1 ` . 007 FLE <br /> 5.Generators Name and Mailing Address Generators Site Address(if different loan mailing address) <br /> L733 �'rs € s HF-A Thi 71<9EeE FAC IT TY (07557� Fit n sos.i'sH i fSSTIN P,01",D <br /> i' C1-! [tEisF� Ali ftp )�G&D (,f:t,. E-1- whztstl e S70('->•WWW, ('A P5215 (attzx <br /> GeneralarsPhone: — <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2Company Name CA'r'a0S 5w9' <br /> U.S,EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> ,V' "31T#TO L C-7 U.S.EPA ID Number <br /> 225-4 E_ 13th ztx4-_ v- <br /> t3 A7. 65365 <br /> FaOilyrs Phone: 928-783-3-175 <br /> �u .G 0520304 <br /> 9a 9h,U.S.DOT Descnpfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> Hitt and Packing Group(if any)) No. Type Quantity WLNoi. 3.Waste Codes <br /> i. .r 4f. Sze rifts&zr3aus �vzL tz_ 'L ; 331 i <br /> watx. �;e emulsir�n3 I <br /> � 2. asNar titer 5=r3.t,id <br /> 223 <br /> 3 <br /> ( <br /> 4. <br /> 14.Special Handling inslructions and Additional Information ` <br /> tit�ea�..z=r �,at�c irsst �rn�a.�.z.ion-T.�.Ri338-T,L1fC�IC�� 2t oi.ii.� zags-r�T3_n# 51t73H•}_5�.�. <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked a labeiedlplacarded,and are in all respects in proper condition for transpo t according to applicable in rnalion and nal I govemmehlal regulations.If export shipment and lam the Primary <br /> Exporlo certify that the contents of this consignment conform to the terms of the allached EPAAcknowledg (of C nt, <br /> I cervi hal the waste minimization statement idenli ed in 40 CFR 262.27(a)(if I am a large quan6ly gener ar(b A am a II quantity generator)is true. <br /> General ' ff Fors Primed yped Name Sig r Month Day Year <br /> .International Shipments <br /> ❑Impart!o U.S Exp ad from U.S. Port of entrylexit <br /> Transporter signature(for exports only}: Dale leaving U.S.: <br /> w 17.TranspoderAcknoMedgmenlofReceipt ofMaterials <br /> Trans nor 1 PrintedlTyped Name ) Signature Month Day Year <br /> CL <br /> Transporter 2 Prinledffyped Name Signature Month Day Year <br /> 1-- <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Paniaf Rejeclion ❑Full Rejection <br /> 18b,Alternate Facility Manifest Reference Number.[or Generator} U.S.EPA ID Number <br /> J_ <br /> FacHly's Phone: <br /> Wf8c,Signature of Allemate Facility(or Generator) Month Day Year <br /> 4 <br /> z <br /> 1g.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLF <br /> 1. 2. 3. <br /> HItil 141 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted fn Item 180 <br /> PrintedlTyped Name Signature "_DaY,-,, <br /> EPA Form 8700-22(Rev.12-17) Previous a (lions are a.b ollite. SIGNA F'ACILITY TO EPA's e+MAN[FEST SYSTEM <br />