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10 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMD No. 2050-0039 <br />EPA Form 87CO-22 (Rev 3-05) Previous editions am obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS I. Generalor ID Number <br />Q <br />2. Page Iof <br />1 <br />3. Emergency Response Phone <br />4.aoltest rac61 <br />0 0046 <br />Number <br />1418 <br />WASTE MANIFEST 4 <br />1.877.818.0087 <br />VES <br />5, GenetaloesName and rfAdd'@,, /• Y GeneralcmisSiteAddress(ddilyrenl than m cling address) <br />�/'1^Vflafty4 <br />5 <br />1 Gd °/ <br />fdit?✓, Cr4.9f20 <br />4(&-G1V�y <br />_ <br />Gamic <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Veda ES Technical Solutions L.L.C. I NJD080631369 <br />7. Transporter 2 Comyamy Name US. EPA x) Number <br />8. Designated Facility Name and Site Address U.S. EPA 10 Number <br />Veotia ES Tedmical Solutions L.L.C. <br />5736 West JefrWon St <br />Phoenix, AZ 85043 AZOOD0337300 <br />Facility's Prone 602-233-2955 <br />ga. <br />91b. U.S. DOT Description (including Proper Shipping Nsme, Hazard Class, ID Numbs, <br />10, Containers <br />11. Total <br />U. Unit <br />Waste Codes <br />W. <br />Type <br />HM <br />and Packing Group (n any)) <br />Quantity <br />vii13. <br />1, <br />RQ. Polychlorinated biphenyls, IIgWd, 9, UN2315, PGfll <br />' <br />�i`1 <br />•� j� <br />K <br />z <br />2. <br />w <br />r.D <br />3. <br />4. <br />14, Special Handling Instructions and Additional Inlpmi; <br />Out of Service Date;_ I/> .� q 0 2 4 b 183 gel ('12 <br />sox vl�/ Doc* -s <br />vooiL/0411 I/ <br />15. GENERATOR'SIOFFERORSCERTIFICATIGR: Ihereby deda, that the contents ofWis consiyimentamit* and accurately described above by the proper shipping new. atm ares classified. packaged, <br />marked and Iabeledfplacarded. and are in, all mispeclso proper condition lorhansport according to applicable inlemetknatand nationd gavemmentsl regulations. if expel shipment and lemons Pdnary <br />Exporter, I certify that the oontants of this consignment conform to the tams of the attached EPAAck omedgment of Consent <br />I certify, that the waste minlmizi staterrenl identified in 40 CFR 262.27(x) (t I am a large quantity generator) or () (if I am a small quantity, generator) is true. <br />Generalorrsf0tercls Punledrryped Name Signature Monty <br />Jia c�osf� �,7 i..2 <br />J <br />F <br />16. ntemaeotrel Shipments <br />❑Import to U.S. Ll Even from U.S. Port of entryfexib <br />= <br />Transpolar signature (a axpods only): Dale leaving U. S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />TresPoder PrinledRyped Name Signature Month. Day <br />/Year <br />B < <br />Transporter 2 PnntedlTypsd Name e, Signati Month Day Year <br />18. Discrepancy <br />18x. Discrepancy Indication Space ❑ Ouenity ❑Type ❑Residue ❑ Partial Rgeclun ❑Full R*ctlon <br />Mandell Reference Number <br />18b. Alternate Facility (or Generi U.S. EPA ID Number <br />J <br />V <br />LL <br />Farsitys Phone: <br />w <br />18c, Signature 01Ademate Facility for Generator) <br />Month Day Year <br />4 <br />2 <br />H19. <br />Hazardous Wasle Report Management Method Codes (Ie., codes lorhazardoies waste treatment, dlspoSal, and recycling systems) <br />01. <br />2. <br />20. Designated Facility Owner or Operator: CeNficeeon of receipt of hazardous materials covered by the manifest excopl as Med in Item like <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 87CO-22 (Rev 3-05) Previous editions am obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />