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Please print or type. Form Approved.OMB No.2050-0039 <br /> 2.Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Nurtiber 9 9 Y q L- <br /> WASTE MANIFEST L AL 000 443 265 514541-2128 0 16 5 6 5 8 8 8 FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Wale 1 #2356 <br /> 1450 N Bonsan Ave STE A 4212 marada Lane <br /> Genera e:CA 91786 909-656-21708 StoWon, CA 95212EPA ID Number <br /> 6.Transporter 1 Cempany Name CAL 040 346 010 <br /> Hio Sky Environmental Solutions <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> Vftldwide Recovery Systems, Inc CAR Number 175 42 <br /> 5.Designated F-t4-NamTand Site Address — U.S:EPA 10 Number <br /> Yuma YES 21Na21e AZR 000 521 146 <br /> 6600 t1S Hkowlil 95 <br /> FacilitysPB AZ 8530 928»344-9828 <br /> 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> Be. Quantity Wt.IVnl. <br /> HM and Packing Group(if any)) No. Type ty <br /> 1. 352 <br /> O Non PiHKardoua 1V7atte Solld (0llyDelarisl <br /> w 2 <br /> Z <br /> W <br /> c� <br /> 4. <br /> %4.Special Handling Instructions and Additional Information <br /> ^3t_ _ , _ - - <br /> ��* 911 - _ <br /> €mergencyCant a01: JIM ITRhodes 51Ill-212$ IAJ�� � <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 labeledlplacarded,and are in ail respects in proper condition for transport according to applicable international and national governmental regulations.It 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 46 CFR 262.27(a)(if l am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Signature Month Day Year <br /> Generatorsl0fteror's PrintedlTyped Name �< 71 <br /> 1�.�K(A!, I k"."- I I I v 1-'� I& I <br /> -J 16.International Shipments Ll Expert from U.S. Porl of entrylexit: <br /> F- Import to U.S. P <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 Printedayped Name Signature Month a 71 <br /> y ,Ygar <br /> rl Month Day Year <br /> Cl) <br /> Transporter 2 PrintedfTyped Name Signature <br /> 5 , M{] -C-) - Z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> .21 Faddy(or Generator) =II.S.ERA 1D Number <br /> J <br /> U <br /> Li- Facility's Phone: Month Day Year <br /> w 18C.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> Q 1' � � 1 � � 2. <br /> 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name - Signature Month Day Year <br /> �I� f t r(- r ( —i {U(( r n i ( 0 )tc I <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. [ ESIGNATED FACILITY TOG NERAT01 <br />