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-- <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter. l Form Approved.OMB No.2050-0039 <br /> `UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManNest Tracking Number <br /> :1 WASTE MANIFEST I CACWZ332 t 5 1 '1 &QD 424- 0048 22970 JJ K <br /> 5.Gerterahtes Name and Mailing Address Generators Site Address(If different than mailing address) <br /> tX41 CED'STATES 8M-- ARCi 2(>AD 1 4025 ARCH ROAD <br /> 1151 W. ROBIN Hoot)Oft BTE 5+1 F;Tr7t;KTTON,(:A Sri1:�15 <br /> STOCKTON,CA 16;'07 <br /> Generators Phone;?(SI)- ,it-tl <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FFREMUWV EWRONMENTAL SERVICES RVOT ict"h,M 800569m?,274 C.AR000171017 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 21st GEAffUR'e.C.PIVtff(vjMlEN TAL M"(m-:W-N7 OF NEVADA.LLC CAR000104012 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 15 21ST Ch'WLAN['EMI N.IVC7980t *i.331J <br /> NI:Wl.AtNQ.S f7RlVE., f:AfzT <br /> f'F.RNI.EY,NV 8940A <br /> Facil' s Phone: <br /> ga go.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Facial Group IN any)) No. Type Quantity WWd. <br /> a: 1' Rest"::;::rkdlcat,3.1Rd186SI it' 3q3 Ofkji <br /> C)13 4s� � <br /> cz7 3' War to Va"Reiatarl h.4n:=aicd5.3,IJfvl 263,111(Commc lity Poilk) G :343 DWI <br /> 3. .VFwatstk'-ri:+6+cala6&+tE+131cI:3ao. -.!i`te-°_.g a5t1�'Y'iaacik) ...Ci .,:. ntu71. <br /> SFT <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> l WvXzxs to toe,4iN1t trained arxt tr-iE{rise. <br /> Ubt)3915111.00 (2)1CSC. [Rt;s f€1u'7 Nt� EXV-Loi,'3 <br /> %2)3$89;9 dt3 E.RG M 178 <br /> 15. GENERATOR'81OFFEROR'S'CERTIFIOATION: I hereby declare that the contents of this consignment are fully and a=mtely described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper rwndiAan 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 /> rUfy 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 We. <br /> Gentefatorsl0lfemfs Pd yped Name - Signature :' ,. r Month Day Year <br /> 7 " <br /> -..z 16.International Shipments <br /> E - - -"' <br /> F Impodio U.S. ❑Fxpod from U.S.✓. Pat ofentry�sxrlt' ^ <br /> = Transporter signature(for exports only): Date leavI6 U.S.: <br /> W 17.TransporterAcWrowledgment of Receipt of Materials <br /> Trans r 1 PdntedrfgedName Sl as <br /> Monro Day Year <br /> zQ Transporter2PrintedRyped Name - Signature Mdnth Day ear <br /> C <br /> r <br /> r18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 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 /> U <br /> LL Facilftys Plane: <br /> aW fact.Signature ofAhemate Facility(or Generator) Month Day Year <br /> 2 <br /> h18.Hazardous Waste Report Management Method Codes(ji.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manffest except as noted in Item 18a <br /> PdnLdlTyped Name Signature Month Day Year <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />