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Please print or type.(Form designed for use on elite(12-pdch)typewriter.) i <br /> UNIFORM HAZARDOUS IG Rrator lD Number p P Form Approved.OMB No.2050.0039 <br /> Page 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAA OO 777A?7rt r!I� .) ' q 'i' cur,CY G B F <br /> i.: aJ <br /> 5.Generators Name and Mailing Address Generator's Sile Atltlress(rt tliflerenl than mailing address) <br /> 402£.f. <br /> 5TC�: <br /> Generators Phones`'=° :6$14 i Y <br /> 6.Transporter 1 Company Name US EPA ID Number <br /> MAtk1::Ft!A4.7 ,E y yYiAS i t licit. iP7_ <br /> t'Al LVJ8,1, <br /> 7,Transporter 2 Company Name <br /> < U.S.EPA ID Number <br /> If .1 reI+ r ', () ir sit 1,1 It v� P�k�ra �- f iotxr�l�fd% <br /> 8 Designated Facildy Name aM site Address 2151.CEH1t1RV t ROi�NxiE1fIAL MGMT F NEVADA ac U.S.EPA ID Number <br /> 2086 NEWLAW)S OR EAST Mlfv§SOBg483S <br /> FER!"IL ,14V 68401% <br /> Faaiify's Phone: 7.42hi) <br /> go 96.U.S DOT Descapeon(including Proper Shipping Name,Hazard Class,ID Number, i0Containers <br /> HM and Packing Group IN any)) 10. 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WtNoI. <br /> 1. tlfr90$7 l4yvTARDCJ$WASi E,I.1(YJi D,N.O.S 9YC�1UI <br /> Fo ', IRf KRi[XsERATOIN Oli VJ1TMi TRACES OF FRFONI x'- � <br /> of —. <br /> LU <br /> W All <br /> - <br /> � I <br /> z 2. <br /> 3. <br /> R C I /ED _ <br /> DEC 05-2 <br /> 4. <br /> ENViR NM NTA HE T_H- <br /> 14 Special HandlinglnslruciklnsamAdditional ln�ornation EPA TM �NT <br /> YROf'1LEk 40234-0fi REFER IOk Witt' rk,410ESGF FREiNJ <br /> ERGs 111 <br /> fAFRGPN Cf pill Ari RgESF,In <br /> 15. GENERATOR1101'PER0R'S CIVK Ill JUN: I hereby declare that the contents of Ods consignment are fully and accurately deacrbed above by the proper shipping name.ard are c assified,packaged, <br /> marked and labelackplanarded,and ere in all respects In ProperoondObn foreanspod accordingtoapple mia,ntemalfonaland national governmental regulators.IIexposshlpmenlandIamthe Primary <br /> Exporter,I certify that the contents or this consignment conform to the tents of tla attached EPAAcpnowletlgment of Consent. <br /> I candy that Ota waste mimmbatioo slalemenl IOenlified in 40 CFR 262 27(a)(if I am a large quarry gererator)or(b)(if I am a small quantity generator)is We. <br /> Generelory00erors PnntetllTypetl Name Sign.u. Month Day Year <br /> E' 8 <br /> F16 International Shipments ` T r 1• <br /> ❑1hipat b U.S ❑Export from U.S. Portofentryfex,7: <br /> Transporter signaNre(for exports ordy): Date leaving U.S.: <br /> w 17.TranspoderAcknowledgmenlof ReWptol Matenals <br /> Transpan 1 Pn .Typed Name <br /> r Sgna ure �'•ry <br /> aO Ila, "•'/ Monty Day Velar <br /> ZTrans er 2 Pn led-yped Name Sgraf6re <br /> 19 <br /> Ml Day Your <br /> i18 Discrepancy <br /> 18a Discrepancy Inclusion Space ❑ puan4ty ❑ <br /> TYPe El Residue ❑Partial Rejection ❑Wp Rejection <br /> ttizal Reference Number: <br /> 186 AAemate Faoatty(or Gene <br /> 18b <br /> EPA ID Number <br /> J <br /> v hin the OpprOprill pwithriKS) <br /> LL Facility's Phone: <br /> Maj 18c Signature ofAllemale Facility for Generator <br /> ~ this genwotor IS S1flpplrg. Monts Day Year <br /> Z <br /> N19 Hazardous Waste Report Management Method Codes(re.,codes for hazardous waste treatment disposal,and recycling systems) <br /> C I 2 3C.. <br /> 1 20 Designated Fac,bly Owner or Operator Cami6[arion of scepl of hazardous materials covered by the manifest except as noted in Item lea <br /> Pnnledrryll Name Signature <br /> f '( , Monthyear <br /> EPA Form 0700.22(Rev.3-05) 1-haVa s actions are obsolete. F <br /> DESIGNATED FACILITY TO GENERATOR <br />