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u <br /> Please print or type. Form Approved OMB No.205,:-,7038 <br /> UNIFORM HAZARDOUS 1.Generatur ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manlf"t racking Number <br /> WASTE MANIFEST a-AL[1FJlAh0.tHi5 r cYl�+ j:$� l+IJkJI 3 �" JJ K <br /> 5.Generator's Name and Maiimg Address Generators Site Address id differenttltan margrig address] <br /> VAL TFt11i NW <br /> 4140 E.PEL11W <br /> AC-A two.LA 96220 <br /> Seneraror's P#rona7Ug•3.?'4-�� <br /> n Transporter 1 Company Name U.S EPA ID Number <br /> AA11�Fi1 AN MM-LE:Y V"TE-(AL.INC LAFttxFD712X- <br /> T Transporter 2 Company Mame AMMAN <br /> S EPA Ip Number <br /> w(AkLrmDE F7I`Ct7W Y MTLMS INC CAR"1175422 <br /> 8 Designated Faplity Name and Site. dream U.S EPA ID Number <br /> I UMA Y S 2 WANE i RANL4F LR FAL U 3 Y ARZOM21148 <br /> X00 US HC*WAY 96 <br /> law AZ 85365 <br /> Facility's Phone:929-344-W28 <br /> ga. 8b tf S.DOT Description IMuONN Proper Shipping Name.Hazard Gass.ID Number 10.Containers it.Total 12 Unit 13.Wade Codas <br /> HM and Packing Group(if any)) No. Type Quantity wt'Vii <br /> 0 W)N PC RA hiAZARDOM WASTE SMUS,AMORSEWT5 A Qt, t [ M <br /> d PAPER FILTERS <br /> rr <br /> Z 2 <br /> w <br /> C7 <br /> 1:4 Special Harding Instructions and Additlorial IMomhaWn, <br /> "1dL)f iL" 1$3325 414 PAPER F Ii••_.k; LR6 1 I i <br /> '_lrI -W[ I WY CONTACT DEf"E <br /> GENE RATOB'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of This con6lgnment are hilly 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 canditlon for transpW acro ding.to applicable intematronai.and national governmental regulatimfs.If export shipment and I am the Primary <br /> Exporter.I ceM-fy that the contents of this consignment conform to ft terms of the attached EPA Acknowledgment of Consent. <br /> I cenbly that the waste mrNmlzatlon stalemenl dentifred in 40 CFR 262.27(a)[if I am a large quantity generator)or(0)(if 10 a small quantity generator)is true. <br /> 6enerSlQifaror's Pr nledlFyPed Name g takrre M Day Y98r <br /> ff T <br /> -•� tie i � �J� rf1 <br /> iii E bematica al Shipme ns <br /> � ❑Impdrt to U 5 ❑Expprl from1w5 Pan of enfryf&xrt. <br /> Transporter signature ffor exp"only): Date ieavmg U.S.: <br /> W iT Transporter A�gm sM of Receipt of Matenals <br /> E� ?ra r 1 yped Name ] S Month Day <br /> y ransporter 2 Pon irn yped NaSignature MnrtB aayL-47 <br /> tc� 1 7-3 <br /> s .Eiscrepancy —J <br /> 18a Discrepancy Indication Space <br /> ❑ 4rranhry ❑Fype Re-J{due Paltia3 Rsje(trnn Fu11RcyeCtror <br /> Manifest Reference Number: <br /> F 1&b.Alternate Facility[or C,"rator) U.S EPA ID Number <br /> J <br /> U <br /> Facility's PNme: <br /> W 16c Signature of kernalle Facility for Generator] Mond Day Yea: <br /> Q <br /> y19.Hazardous Waste Report Management Method Codes li.e. edea for hazardous waste treabnent.drsposai.and recycling systems) <br /> o v. 2- 3 4. <br /> 20.Designated FwAy Owner or Operator Cerhflcation of receipt of hazardous materials confed by lie mare#est except as noted in Irem 18a <br /> Pnnted+Typed Name. S 5 gnafare Wnth Day yea, <br /> EPA Form 87W22(Rev.12-17) PrevioL*ecirtioris are obsolete. DESIGNATED FACILITY TO GENERATOR <br />