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P.. <br /> 7142 • , n • ^Tri _��:-. you' <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) a'`I' " Form Approved.OMB No.2050-0039•- <br /> UNIFORM HAZARDOUS 1.GeneralorlD Nu er q 2.Page 1 oP 3.Emergency Response Phone 4.Man ifestTnckin Number. <br /> WASTE MANIFEST CA.d°I 1 ( �j ,,1;;:;:2��0®-468-176 003324783 SKS <br /> 5.Geemptoes Name aMaiI Addssi Generator's Site Address If different than willing address) <br /> 'L 00 Ki✓�6ve 1 Rd ' . <br /> Tho,,44a GII <br /> Genaratafs Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS TXR000081205 <br /> 7,Transporter 2 Company Name yyU.$gS.EEPPAAp ID Number <br /> 8.Designated Facility Name and Site Address US ECOLOGY NEVADA 1`C`1'9TkD Number <br /> 11 MILES S OF BEATTY HWY 95 ';';7' ! <br /> BEATTY ,., r1V,:89003 <br /> Fatillys Phone: 600-239-3943 NVT330010000 <br /> 9a 9b.U.S.DOT Deaaiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group if any); No Type Quantity MANoI. <br /> z 1'NON RCRA HAZARDOUS WASTE SOLID 4, DM Q-0 P 352 <br /> a� I (ABSORBENT AND OIL) <br /> 3. <br /> z <br /> 4. <br /> i r <br /> e _ <br /> 14.Speual Handling Instructions and Additional information SK SHIP*208246535 CSG: <br /> 24 HR EMERGENCY *1-800-468-1760 (SAFETY-KLEEN - CONTRACT *94138) 06 _ 5 <br /> T T V <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the convents of Mis consgnment arc�ulyandamuatetydesrnbedahove by Ne proper shipping name,and arta oassifiedpackaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable htemationaland national governmental regulations.Ifexport sMpmenl and I am the Primary// <br /> Exporter,I cediy that the contents of this consignment conform to the terms of the attached EPAAcknowledgmant of Consent <br /> I cer6y that the waste immin za0m statement dendfied in 40 CFR 262.27(a)(it I am a large quantity generator)or( if I am a small quantiy gener is <br /> General Offerofs P htedRyped Name Sign amr Month Day Year <br /> � jd l rc <br /> 16.Infamalional Shipmen6 �- <br /> F / ❑Import 10 U.S. ❑0pon from U.S. Poco olentry/exit: / t <br /> Transporter signature(for expomi Doty): Date leaving U.S.: <br /> W 17.TranspaterAcknowled9ment of Receipt of Materials - <br /> O� T 'ri PrnteQ4ypetl Na SignaNre hJon(p Day Year <br /> QTransporter 2 ProedTfyped Name� �'. Signature tMonth Day- Year <br /> K <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Portal Rejection ❑Full Rgecuum - <br /> 1' <br /> , - <br /> Manifest Referanca Number. <br /> 18b.Alternate Facility(a Generator) U.S.EPA ID Number <br /> J <br /> LL Facilltys Phone: <br /> 18c.Signature ofAltemate Facility(or Generator) - Monty Day Year__, <br /> z <br /> y19.Hazardous Waste Repod Management Method Codes(i.e.,codes for hazardous westo diamond,d'epxal,and recycling systems) <br /> i. 2. 3. 4. <br /> w� <br /> 20, signaled Facility Owner or 0 rotor.Certification of receipt of hazardous materials covered by the manifest except as not in lteml <br /> PrinteNTyped NameS[gnatu Mon Day Year <br /> 2 <br /> EPA Form 0700-22(Rev.3-0 Previ6useditionsamo solete. DE NATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 1)400056/123 <br /> 11387.0560 <br />