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Please printor type.(F rm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Pae 1 of 3.Erne envy Res onse Phone A.Manifest Tracking Number WASTE MANIFEST C A L O O O ?4 3 0 7 (s o)42+ �sC4 0177-92131 J J K It 5.Gan t rs N Ikn� ddress �`, Generators Site Address if different than mailing address) rPf �'b j <3 (d/ ; 201 E ORCHARD STREET HAMMONTON NJ 08037 1401 SOUTH CHEROKEE LANE 208 365-0175 LODI CA 95240 Generators Phone: 6.Trans 1 c 9Ur'MMNMENTAL SERVICES Ws.WNVUra 7 7 0 S 6 E U.S.EPA ID Number 7.Transp9ft�r�iC,Qrpp� E"Pr-COVERY SYSTEM INC. CRR 0 0 017��4 2 2 8.Desi Wtg fFacE(Jlity+� � Iiad Site Address U.S.EPAlD Number �n 2730 E 13TH ST YUMA AZ 85365 AZR000515924 FaefiiWsPhone: (828)3445$28 ga. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,Ib Nomber' 10.Containers 11.Total 12,Will 13.Waste Codes HM and Packing Group(if any)) No, Type Quantity 4Vt Nal. 1.NON-RCRA HAZARDOUS WASTE,SOLED(BRAKE LA HE s AVI0s) s� Z 2. W 0 -- - 14.Special Handling InsUvctlonsandAdditional Information EMERGENCY CONTACT,CHEMTREC 1-$00-4249300 WOES TERMINAL:ORES CS *PROFILE#9I31;161623NRS f Ef 344 BRAKE LATHE SHAVINGS *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 2c l y 15. GENERATOR'SIOFFEROR'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,packagod, marked and labeledlptacarded,and are in aft respects in proper condition for transport according to applicable international and national go%;pmmenial regulations.If export shlpment and I am the Primary Exporter,I certify that the contents orthis consignment conform to the terms of the attached I;PAAcknoMadgment 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)(Ill am a small quantity generator)is two. on rator'sfOfferors PdritedfTyped Name gnattne Month Day Year" «a 16.International Shipments ❑Import to U.S. ❑Export from U.S. Pori of entryfext: Transporter signature(for exports only): . Date leaving U.S.: I'. 17,TransporterAcknotvledgment of Receipl of Matedals O � Traras'�pr{pr 1 PrinRad VON � n� Signature Mgilih" pajl:7T Year- Transporter PhOdfTted Name Signature Month tray. Year H 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parliai Rejection ❑Full Rejegtion 5 Manifest Reference Number: illb.Aitemate Facility(or Generator) U.S.PPA ID Number tai. Facilily's Phone: w 18c.Signature efAltemaluFacitity{or Generator) Month Day Year tc z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste ireaiment,disposal,and recycling systems) 3. 4, 20,Designated Facility Owner or Operator.Certtfleation of recelpl of hazardous materials covered by the manifest except as noted in Clem 16a PrintediTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE(IP IIrEQUIRED)