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�:. Form Approved.OMB No.2050-0039 —4PM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone1.Manifest Tracking Number WASTEMANIFEST LltiUC'1i114iU lnfl' r,l;-; -.r. O JJ K r 5.Generator's Name and Mailing Address Generator's Site Address if different than mailing address 1:21.14il L Fv1A11d 3 f 1 ki K I U14,LA 952LIb Generator s Phone f3� r�. '35-105 6.Transporter 1 Company Name U.S EPA 10 Number ARv1d-1=�k.-AN�/�rLLLi"VVH8i�.r�ll..fl�ir. r.;AFFG(iD2/7311ta 7.Transporter 2 Company Name U.S.EPA ID Number W(-"-L)W M-kE�i_�tiJLkY SIS I L-hAS1Ni t A}tUtlflt I$471 8.Designated Facility Name and Site Address YLIMA YES d wAbIL iHMbil—.k FAr IL11 Y U.S.EPA ID Number 0500 US"OMy 05 F Z 1 t46 'AA4A.AZ 85385 Facility's Phone: ga. 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 wt./Vol. IIX1' tltt)N-lIHAZiRDOUS WABIE£'OUDES,A8.:13R8ENT:S a o PAPER nLTCRS W z 2. w 3. 4. 14.Special Handling ns on an on Information F'f?IC7�1l.�A��lL11#SltJi�� L' ' CONTACT JOW 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,art are classified,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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ill am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature ,. _ Month 4y� Year ._ /J rl .a 16.International Shipments L1 Import to U.S. Export from U.S. Port ofentry/exit: Transporter signature(for exports only): Date leaving U.S.: 7.Transporter Acknowledgment of Receipt of Materials ansporter 1 Printed/Typed Name Signature Month Darr Year vA snsporter 2 PrintedlTyped Name Signature Month Day Year Discrepancy Discrepancy Indication Space 0 Quantity ❑Type El Residue ❑Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility(or Generator) U.S.EPA ID Number y's Phone: ignature ofAltemate Facility(or Generator) Month Day Year -ardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Notice: State of California requires 2. 3. generator to photocopy and mail to DTSC with 30 days: gnated Facility Owner or operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P-0 BOX 400 yped Name Signature Sacramento, CA 95812-0400 I -22(Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY