Laserfiche WebLink
Ptease print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> tUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Man((bst Track! Number <br /> WASTE MANIFEST X12 1497'& 'rM V U ,; 4 5 8 FLE <br /> 44 5.Generator's Name and Mailing Address Genera°or's Site Address(if different than mailing address) <br /> f�SOW <br /> Dk (EAMI Won H%jhj <br /> kilil{IILKX CA 91537 <br /> Generator's Phone: om <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AftooW ChwitAi rM*;x:w( ft. CAFdDM%W <br /> 7 Iran �er 2'C'om any NameU.S.EPA 1D Number <br /> Yi�cslttywcfllc ? Smarr', <br /> IFr ft121 <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> Y YES LLCE. is& St ABOM982+6 <br /> Yurr+s�, AZ IM <br /> Facili s Phone: # <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group('d any)) No. Type Quantity WLNol, <br /> 1 Noe-RCRA Hazwdow Wotttlle.Uq M,aAt=Y pabir DIF <br /> a kxwepadO <br /> w <br /> z 2 <br /> LU <br /> C7 <br /> 3, <br /> f � <br /> 4 I <br /> 14.Special Handling Instructions and A fi'g�ial�rtinrmafion - <br /> %V1 P�rut l�itt� ��T�i Dilmsnilell#t: CI1637� <br /> t <br /> Maw . <br /> 15. GENERATOR'SIDFFEROR'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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.@ export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cor4nment 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}pf i am a small quantity generator)is true. <br /> erator eror's PrintediTyped Name Signature <br /> __j 16,International Shipments <br /> ❑Impart to U.S. ❑Export from U.S. Port of entrylexit <br /> — Vans er s nature for expms Only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter t PrinledfTypedJame igaatur� `t r on ear <br /> 15 <br /> CL w <br /> Tn of 2 PinecUT., Signature onay earZz / 'l <br /> 18.Discrepancy+ /f <br /> 18a.Discrepancy Indication Space 11 Quantity El Type �7Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> C.7 <br /> a <br /> Facility's Phone: <br /> 18c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> CDa <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I i < 2. 3. 4. <br /> 20.Designated Facility Owrtertipr Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Fyped Name Signature Month Day Y r <br /> CA <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />