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Please print or type. 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 � G D F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Mw NEWTON RD. <br /> S1 C7(:Kl_OR CA 1�5205 <br /> Generator's Phone'''` <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 1NIEKK-:X4 VALLEY V44 TE 04L_ ING I-'ARR000272 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> AJ*DFit-0VV1DE RE�4AEHY 5"S TEM: tt1 C A.RIJW11754 221 <br /> S.Designated Facility Name and Site AddressYUMAYES k WASTE I KAN• IFEH FAULITY U.&EPA Ip Number <br /> CtSWu-Srfir ArDDyl MA.A2 <br /> gtR it�4� <br /> Facility's Phore�28-344# <br /> kQu <br /> gal 9b.U.S-DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Totai 12.Unit 13.Wase Codes <br /> HM and Packing Group(if any).} No, Type Quantity WI.Nol, <br /> 1 tX)t+RCRA hX'ART)()IfS~-ZTF v;01 1t1.AR.tt0RRFNTS.x Ott. <br /> P PA}FR FILTERS <br /> ;u! <br /> z 2. <br /> lu <br /> tD <br /> 3. <br /> 4. <br /> i <br /> r <br /> 14.Special Handling Instruct'ons and Additional Information <br /> i'ROFILEk 315II09l6NR5 ABSCPItBENI,PAPP R Fli.TEFU ERG# t7 t <br /> E%IEtRGaCY r't'M'ACT:EFRW <br /> 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,packaged. <br /> marked and Iabeledlplacarded,and are in all respects in proper condition fortransport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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)(ifl am a small quantr y generator).is true. <br /> Generatorsf0#feror's Printedffyped Name Signature Month Day Year <br /> J IS.InrernationalShipments <br /> ❑Import to U.S. ❑Export from U.S. Pori of entrylexit•. <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> iX 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 RRedffyped Name Signature�.�- - N,q w- Month` D ,Y Year <br /> Transpprter2 PrintedFryped Name r` Signature Ponth Day <br /> r <br /> 18:Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(or Generator). U.S.EPA ID Number <br /> J_ <br /> ri Facility's Phdne: <br /> LLI 1 Br-Signature of Alternate Facility for Generator) Month Day Year <br /> Z <br /> 05 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 24.Designated Factlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous edifons are obsolete. GENERATORS INITIAL COPY <br />