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Please print orlype:(Form designed for use on elite(12-1 typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 11,Generator ID Number 2.Page 1 of 3.E mergency 777 Response Phoneking Number WASTE MANIFEST K 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) x Smog W FA-.":' -Loc-fs' on, C A 9 5 21'-t om Generators Phone: 6.Transporter 1 Company Name WASTE } U.S.EPA ID Number /- YV �I�t'�. Y L ... �J Y ? r. 7.Transporter 2 Company Name U.S.EPA ID Number r 6 CA :� 175 422 8.Designated Facility Name and Site Address U.S.EPA ID Number S US Righway 95, Ylima , Arizona 85365 Faciliy'sPhone: 928-344-984--'a I A R 00 521 146 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 1 0 oil/ DIM NnN-RCRA HAZARDOUS WASTE SOLIDS w Z 2. LU C7 3. A. _�._.. 14.Special Handling Instructions and Additional Information AND USE PPE 15. GENERATOR'81OFFEROR'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 labeledlplacarded,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 eertity that the.contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(il am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generatoes/Te-Vs PrintedfTyped Name Signature Month Day Year V ,J 16.international Shipments H ❑Import to U.S. ❑Export from U.S. Port of entryfexit: _ ? Transporter signature(for exports only) Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials �2 Transporter 1 Printed/Typed Name Signature Month Day Year ZZ Transporter 2 Printedrryped Name = Ignatrare Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: H 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: LLI18c.Signature of Alternate Facility(or Generator) Month Day Year Q 2 U519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. T. 3. 4. 20.Designated Facility Owner or Cperator'Certhcation of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnntedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR