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Please print or type. <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />1 <br />7. MLUUU Iiv,13blti 7(r. �' t . <br />lUb iusxSi:t-III . <br />0 v u 2 Al 0 U66 G BF <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />KALENLKS AU10 WI ECKRAG <br />+323/ h HWY Ifs <br />Z 1(1C:K*10N, GA 1!62'15 <br />Generators Phone:,;; <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />,% .KIC;AN VALLEY WAS IE:OIL, INC:. GAR000272302 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />VYVRLI)VVIUE KEGOVERY SYS iI-M:S INC CARUOU'J 16412. <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />'AJMA YES t WAST It: I RN4SUEK FA(:ILI IY AI140006- 21 I*d <br />(1500 U5 HIC.*MAY 95 <br />y1lMA, AZ 6151S65 <br />Facility's Phone: #28-.1q J8A 3 <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />0 <br />1. <br />N011`4-RCRA HAfAR(". .JS WASTIF S01.I0, ABSORBENTS. Off- <br />z <br />2. <br />w <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />I'Itul 11,10 1W1,iUl6Nh.S At3:s0RBVNl, VIL kKLW II <br />(;t:NIA(j'1 HAI PH <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 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) lift am a small quantity generator) is true. <br />Generators/Offerors Printedffyped Name Signature Morift Day Year <br />H <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />1-- <br />o <br />Trans c)ter 1 Printed/Ted Name Signature 7 / Month Day Year <br />ZTransporter <br />2Printed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type Residue Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />0 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. 2. Notice: State of California requires <br />J. generator to photocopy and mail to <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days: <br />Printed/Typed Name Signature P,0 BOX 400 <br />Sacramento, CA 95812-0400 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />