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IA5-0t <br /> C( <br /> Please print or type.(Form designed for use on elite(12-pitch)i writer.) • Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number t 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking( <br /> Number <br /> f7AD4$.I`.> , i,Cr,. .1 A .. <br /> WASTE MANfFEST 1 1-80o-4f58-1760 ��t..1f +tin SKS <br /> 5.Generatoes Name and Mailingg��Address Generator's Site Address(If different than mailing address) <br /> SAN 10AV. V1,y'ONAI. TRANS <br /> 1533 E' LINDSAY ST ATTN TRANSIT DI"TR1 <br /> STC+Ci{TON CA 95205 <br /> Geneerrattpopr'ss P[h'onep:t0pa21�v0,y9 <br /> 6.STrt! L'1'T CK,LCP 1ma Th IS, INC U.S.EPA ID Number TXROOOD":� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address US ECOLOGY NEVADA 050505 U.S.EPA ID Number <br /> 1114ILE5 S. HWY 95 <br /> BEATTY NV 0900s <br /> 7'75-553-220`.4 NV'r330010000 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 1NON RCRA HA"ARDOU`,', WASTE SOLID DM P NONE 352 <br /> o ABSORBENT A411 OIL ) _ <br /> 0 - <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SY, TPC'K#10852374 Or„d... I ,, 76T- <br /> SK <br /> SK NU'THORISEII TO RETAIN LICENSED fsM',EQUENT CARRIERS A+ ,' NECESSARY <br /> 15. GENERATOR'SIOPFEROR'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 labeled/placarded,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)(8I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> GeneraWsllMeror's PrintedfTyped Name Sgnature Month Day Year <br /> v ' <br /> t;�.1 r.:3 '•'y i.-.V C4 ,.,Cr ;„� i I <br /> J 16.International Shipments ❑ rt from U.S. Port of entrylexif. <br /> F [1 Import to U.S. Ex po <br /> M Transporter signature(for exports only): Date leaving U.S.. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> K Transporter 1 PrintedRyped Name Signature Month Day Year <br /> Transporter 2 Pimacirfyped Name Signature - - Monro Day Year <br /> C <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Ahemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Monro Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 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 /> Pdntedffyped Name Signature Month Day Year <br /> Eft�p�rr�8j10,(E2J(Rev,3-05) Previous editiogsare obsolete. } I GENERATOR'S INITIAL COPY <br />