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Please print or type. (Form desi ned for use on elite (12 -pitch) typewriter.) <br />F A <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />orm p roved. OMIT No. 205u-vuaa <br />4. Mm t Tracklna Numt»r <br />WASTE MANIFEST <br /><: ,A L � of )rI d ', ( <br />800.4249300-C+1Ef�TTFtEC; <br />014 8 ;1 JJK <br />5. Generator'�JJame aodl <br />` ailing Address Generator's Site Address (if different than mailing address) <br />Ta : T <br />_ <br />16Z r A. <br />Generator's Phone: (Z N % <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />F•E;EMtOl1W E'N'VITtC�tI'AEpfTA!_ SERVICES iNt; f�'trot� ft t',Utb fi5li-32 r4 C',1f?ftt'r) t 7 l rri <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />21st CENTURY ENVIRONMENTAL W1,4A0E:ft>'1FNT QF NFVADA, I.L(; <br />B. Designated Facility Name and Site Address 2'I ST CEFTTURY EMI U.S. EPA ID Number <br />21795 NEWLANIt' DRIVE. f:A.5 r D1trOnAt?ti�+5338 <br />FERNLEY, NV 394013 <br />775-5r5-;.Yrfta <br />Facilit 's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WL/Vol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />Lull2. <br />1 <br />W11.777, i �,;4j t15'r 1^"`Jv�4�t.• L•,QcN V✓, :.'f C�rlii,7,••[r <br />O <br />i L•e-4 <.r7;�'r f -•fid I?_%r'-7)-l78,11 <br />17F <br />),.+5 <br />-1 <br />1' <br />i)2 -1 <br />t. <br />BVI <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />Handlers to be 40hr train>d and usc� PPE <br />9bl)386168-G`0 ERGO III <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 labelediplacarded, 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) (if I am a small quantity generator) is true. <br />Generator' rWs j ntedlTyped Name Signiat6re Month Day Year <br />J ': <br />-s <br />E- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. 1. 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 f <br />Transporter 1 Printed/Typed NaTp--•'' Sig ure I Month Day Year <br />Z <br />R <br />Transporter 2 Printedrryped Name Sigdature,Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />ra+ <br />Facility's Phone: <br />C3 <br />18c. Signature of Alternate Facility(or Generator) <br />Month Da, rear <br />6, <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1 <br />2. <br />3, <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item I Be <br />Printed(Typed Name ) Signature ` q Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />