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frl r r � < � O <br /> o O <br /> 3 085, <br /> iv W NO O ONS <br /> TI W C� *k N 0 <br /> O Ox <br /> W O (p *k <br /> M ` " m a <br /> U) 'lease print or type, <br /> 11I�IIlI I I IIIIIII�I IIII I�I I� Form Approved.OMB No.2050-0039 4 �. W <br /> UNIFORM HA7ARp0U5 7.Generaw to Number N N 7 r <br /> WASTE MANIFEST 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number O O(Q C <br /> S.GeneratosNameandFhe;Ii ' dress" 0131.23980 FLE 3 L v. <br /> Generator's Site Address(if diberem than mailing address) <br /> r <br /> I')i! 3 Max W?9$ N N N <br /> N J51 fi h1 3?• wiii i Lakes 1` Iii I II r,Nl", 77 <br /> Caene�atefs Phone: '.'4: '^<"Y:�«3 Qllcl t l I t kr .�-F Q N <br /> S.Ins parry Name 1 - cn <br /> parlor 1 Com - 1 EPAID Number N n <br /> ICD <br /> 7.Tran ito4er 2 Company Name U.S.EPA 10 Number `G p <br /> „ .. �. <br /> 8,Desgt>aSed Facility Name and Site Address U.5.EPA 11)Numbef <br /> Yu�ta Yes, I_LE <br /> CID <br /> O <br /> 2730 E. 13th Street <br /> Y upli AZ 9 a3ia.:i fv C7 <br /> Facilitys Ptwne _, <br /> CL <br /> ga 9b.U.S.DOT Descdption Including Proper Shipping Name.Hazard Class,10 Number 10.Containers 71 Total X72.Unit 13.Wasle Codes Q <br /> HM and Packing Group(If any}} No Type Ouantlty MMI. C <br /> o loft RCCA hazardous wa-I liyuiai el'r' l :1 e1,ry:3 ti' St CD <br /> n <br /> i 2. <br /> Lu �' <br /> 0 <br /> N <br /> 7 <br /> 4. X <br /> n <br /> CD <br /> 14.Spacial Handling Inshuodons and Add"ii Information 5'. <br /> 1. i!Y '.Fyj'iCiil §rift (;• ri [4 n,,4:,i; Iny `r irfrr3rl[.` <br /> O <br /> 7 <br /> O <br /> 75. GENERATOR'5IOFFEROR'5CERTIFICATION:I herebydeclarelhalthe contents of this cansignmenl are Polly and accurewly described above by gra propershippirg name,and are classified,Packaged, o <br /> marked and labele(lplanrded,and am in all respects in proper condidon for transport according to apPlicable inlemadonaI"natjatal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerfily"t the contents of thie con n'nt conform to the terms of the attached EPAAcknoWedgmerd at Consent. p/y <br /> I certify that Ore waste mimmizaann statement identified in 40 CFR 262.271a)(if I am a large quantity gen (b}(ill am a small quantity gene tor)is We. <br /> $gnatere � f \ Month bay Year Q <br /> Generaiotsl0flemrs PrtrtedlT ame I <br /> / r.. 3 2 i! 7n 1 <br /> 16.In tibnal 5p5 nts <br /> Export from U.S. Pod or erayleiult 7 <br /> ❑Import to D.S� Dale leaving U.S.'. 1 �. <br /> ? Transporter signa!(ire(forexports only)- _-. •� o <br /> K 17.TransporterAcknowledgmerdmRecHptMMaterials Signature Manch Oay Year 3 <br /> � . <br /> TransPader 1 PrintedlTyped Name <br /> ' <br /> a • s r I hi rrr'_'7+'y Sg <br /> nature Month Day Year N <br /> z Tm,:r-4er 2 Pdnletlffyped Name <br /> Q <br /> F <br /> it n.....epancY <br /> ❑Tye ❑Residue ❑Partial Rejection 17 full Rejection C <br /> Iia.De aepancy Indication Space ❑puerility �CC <br /> Manifest Ralemooa Number, G <br /> US EPA iD Number <br /> Au,amale Facilty(or Generator) <br /> O C (D <br /> v 00 <br /> LL F'. SPhon: "so Day Year <br /> w 16..Z,gnature of Alternate Facility(dr Generator} <br /> aCID <br /> I amen)Method Codas Ike.,codes Ior hazardouswaste treabnent,disposal,and recycling systems) <br /> 11[ Ia,rla ardour Waste Report Mang <br /> z. N <br /> CON-1-of receipt of hazerdars materials covered by the manifest esrxpl as noted in Item!aa ` C Q O <br /> .n fir;gnted Facility owner or Operator:CaNllca Signature _ � <br /> O Month Day Year C O <br /> (Q odn y Name < z <br /> CID N W <br /> W EPA xm e7Do-z2{Rel 12.171 Prevlous edilons are pbsorete. GENERATOR'S INITIAL COPY o <br /> m <br /> CID m <br /> 0 <br />