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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CAL0004 US2TE ! GBF S. Generators Name and Mailing Address Generators Site Address (if different than mailing address) JKC: FRUCKING MOO i ON RG Generators Phone. 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address, L� L r t .r :ti ii. !TY U.S. EPA Number 0x00l hNgHMfAY 0`v AZHOO 'i114d Yrl W, AZ fl53Cio Facili9Js Phone: "o as, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Vill K 1t4(X+RCRA HA=ARI)(JUS NIA;T F 4%01 r , AtI:(1RBF:IFS, 4% OIL 1 tX'.1 15 F* JS2 o WAFER FIlTER6 z Z. w 3. 4 VV 14. Special Handling Instmctions and Additional Information PROFIL" f : :_r4T, PATER 1-11-TERS ERG# 171 thIERGF_hx: : _ 15. GENERATOR'SIOFFEROR'SCERTIFICATION: ( hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, at are classed, packaged, marked and labeled/placarded, 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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 21 (if I am a large quantity generator) or (b) (ifl am a small quantity generator) is true. Generators/Oferors Printedllyped Name Signature Month Day Year 16, International Shipments p_ ❑ Import to U.S. ❑ Export from U.S. ' Port of entry/exit: '= Transporter signature (for exports only): Date leaving U.S.: - co 17. TmnsporterAcknoWledgmentofReceiptof Materials Transporter 1/ (Typed Name _ j Signature,�.r^— , _ Montle Dgy Year z Transpgrtar2 PrintedlTyped Name - - Signature ` — " Month Day, e ' r 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Aitemate Facility (or Generator) U.S. EPA ID Number J U LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year R 2 H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyGing systems) wo 1 . 2. 3. 4. 20. Designated Fad1'dy Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdntedrryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY