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Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �� <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing addreK <br /> ss) <br /> LOUISEAVE <br /> i:iiROP CA 95330 <br /> Generator's Phone: 2098%4110 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NVIRONMENTAL SERVICES <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> RECOVERY SYSTEM INC <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> , 600 Ju HIGHWAY 9b <br /> YUMA A <br /> Facllitys Phone: '.'�2$1344-982t <br /> A?P00052114C <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if ani No. Type Quantity Wuvol. 13.Waste Cortes <br /> trot <br /> K i i. <br /> w <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> i_MERGENCY CONTACT:CHEMTREC 1-800,424-9300 WOES TERMINAL CERES CS *PROFILE N 981 :162623NRSTEM,5 <br /> "ILY SOLED * k APPROPRIATE PPE. F^UIPP1ENT <br /> D <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: I 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 and labeled/placarded,and are in all respects in proper coni for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cemly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Pnnted/Typed Name - Signature Month Day Year <br /> a <br /> n <br /> Q Transporter2 Pnnted/Typed Name Signature Month Day Year <br /> K <br /> H <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Padial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181).Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Wk200esi;gnated <br /> 18cSignature of Alternate Facility(o-Generator) <br /> Q Month Day Year <br /> 2 <br /> hs Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 2. 3. 4. <br /> Facility Owner or Operator:CeNfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />