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7707-T-44 LA05 � to RECEIVED <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Oct 4, 2019 Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST L;ALIX YM-,l8" ' 1 ; ,. B F <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> M10 VAI_LFY A(;RIl:IJL ILJRL V(; <br /> 16401 E HWY 26 <br /> Generator's Phon <br /> I..INI7t-N C;A H�:S',',ti <br /> �� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AAAf:RI(:AN VALLEY WAS I Jr: CAA . Ire(; CAR0002/2:V.) <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> VV(NdLIJWiUk:RIi L;UVk-RY:i1':,ILM,`i IW', C:Af2(MI is A22 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> YOMA'1"F.J 2 ftVillL I 1; FA01,I t'y AZR000a:)114ti <br /> rryiJU L,:i FfI��t1W:�,r £i:, <br /> Facility's Phone"2&344•V826 <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> M and Packing Group(rf any)) 13.Waste Codes <br /> H <br /> No. Type Quantity Wt.Nol. <br /> NC1N Ft(:ltq FiAlAi2fXN f WA,-:-fF �:f,71 II1 A(4 tilli2Rf=h41! i)IR I'FL r"tll 1 14.4 ('l I' <br /> PAPFIR Fil TERS <br /> z 2. <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 111"'OFILLA 114f2t",tU PAPEK I-ILILK5 k7k%.4 1 I <br /> rMER(3k-NCY COIdTAC:I KIWN <br /> 15. GEN ERATOR'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 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 <br /> Exporter,I certify that the contents of this consignment 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)(if I am a small quantity generator)is true. <br /> Generator'sl0fferor's Pdrited/Typed Name Signature Month Day Year <br /> 16.International Shipments - <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter,,, t ped Name signature" <br /> 0 /= <br /> IL <br /> Z Tran rter 2 P ntedlTyped/ame J Signature Mdhth Day Ye <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> IZ 18b.Alternate Facility(or Generator) � �O� U.S.EPA ID Number <br /> J <br /> U <br /> uu- Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) _ Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Notice: State of California requires <br /> quires <br /> 0 1 2. 3. generator to photocopy and mail to <br /> DTSC with 30 days: <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature P.0 BOX 400 <br /> Sacramento, CA 95812-0400 <br /> -i L- I <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />