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rJ <br />Please print or type. (Form designed for use on elite (12-oitchl tvoewriter.l I r <br />crHForm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />- - - - rurm mp ravea. UMtS Na. ZUbU-UU39 <br />UNIFORM HAZARDOUS I. Generator ID Number of3. Emergency Response Phone 4. ManifollTrracking Nummber <br />7PPage1 <br />WASTE MANIFEtlfi0•7ME1 fOR CIiEF�1'rS�E.=G' �1 tJP JJ K <br />5. Generator JJama and. Mailing Address Generators Site Address (if different than malting address) <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />FREI'*X 1I ENVIRONMENTAL SERVICES Ill Winne tY 800--55W32' 1 CAR000I r 1011 <br />7. Transporter 2 Company Name 'U.S. EPA ID Number <br />21st CENTURY ENVIf2(ffibiENTAA h1,"'d"AC)EMENT OF NFVA0A. I <br />-Lf_ C:AR0001(M12 <br />B. Designated Facility Name and Site Address 21ST CENrT(JRY EMI U.S. EPA ID Number <br />20195 NEWL.ANDS DRIVE, F:Ac f t 1VOt?90H�t5:1:t8 <br />FERNLEY, NV $1940A <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 />Wt.Nol. <br />13. Waste Codes <br />No <br />Type <br />0 <br />W <br />n <br />2• � �^' i �.� � ,31� r'!Tr }'•1•.��vl •. L��/4C1^I ?✓�, � l C'.i (�• %-�i <br />l C�1 4.c77 )? t rUr Imoi.H' )?",;s ?;7_tai<,Z <br />L�� <br />Li:_ <br />3. <br />4. <br />t— —i <br />14. Special Handling Instructions and Additional Information <br />Handlers to be 40hr irAincad and Lisa PPE. <br />8b1) 386168 -CO 1ERG 0 1 r1 <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 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 06ror's ntedfryped Name Si nature <br />9 Month Day Year <br />—t <br />P- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Z <br />Transporter signature (for exports only): ' I Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter I Printed/Typed Nam.— Signature Month Day Year <br />a <br />rn <br />Z <br />TranspoAer 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Refection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />W <br />Facility's Phone: <br />w <br />18c. Signature of Altsmate Facility (or Generator) <br />month Day Year <br />Q <br />z <br />19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Q <br />t <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 18a <br />Pnntedfryped Name ?- Signature Month Day <br />crHForm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />