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Please pant or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.110 itss!Tracking/umber O <br /> WASTE MANIFEST ti'Al t)Fr�s irai•'� 1 3t.' 4'' .cr it3fs t` e` o M U JJ K <br /> 5.Generator's Name and Mailing Address Generatoes Site Address(9 different than mailing address) <br /> 1616 BOERW-1 WAY <br /> : ll7GKTC)h[ t"A 95206 <br /> Generator's Phonal _"1' 1"': <br /> 6.Transporter f Company Nanta U.S.EPA[D Njmber <br /> Fit %V El IRONk ITAi .`;'J~'HVICES itJt Vlt"w it taW( 5r2e-32"r4 <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> S.:,T CEI'iFUft't ENl) :ARl3 O16S4012 <br /> 8.Designated Facility Name and Site Address US EPA ID Number <br /> 21 S*t CENT AY EMI <br /> 2095WWl..AfM6 DRIVF,EAST AIIJt)iS(IES�a:3 3IS <br /> FEF'I ILFY.NV 69408 <br /> Fatality's Phone:77 'i"5,703 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNcl. <br /> 1. PtaarR4:kA htbrarclou'siAtFTa sc�ildfiltrrr fIPaaSj t fel ! s3I <br /> W <br /> 2. <br /> AU <br /> i� <br /> 3. <br /> l j <br /> 4. <br /> 74-Special Handling Instructiats and Additional Information <br /> '-!A, Dl.ERS TO BF 4CWR fFt/4I2dE11Ai,10 VVEAll F"Pft <br /> 9$11 568249-fX) EFtt`3# 171 <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fulty and accurately described above by Vie proper shipping name,and are classified,packaged, <br /> marked and labek dlptacanded,and are in all respects in proper Condition for transport axord ng to applicable intematiwral and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify Vat the contents of his consignment conform to the terms of ft attached EPAAcknowiedgment of Consent, <br /> !certify that Vte waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Jill am a small quantity generator)is true. <br /> G toeshafferoes Printed/Typed Name Signature Month Day Year <br /> r— �_ t. . I (, <br /> -j 16.Intemational Simon is — — <br /> Z 1 1:1Import to U.S. LlEupod frau U.S. Port of enlryfexit: <br /> Transporter signature(for exports only): Date leaving U.S. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tcan 1 Printer Name Sigpature Month Day Year <br /> za ransporternnted/Typed Name gna fMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> lab.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> � FadWs Phone <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. <br /> 20.Designated Fatally Owner or Operator:Certf"tion of receipt of hazardous materials oovered by the manifest except as noted in Item 18a <br /> PrinledlTyped Name Signature Month Jay Year <br /> EPA Form 870U-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />