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Atype.(Form designed for use on elite(12-pitch)typewriter) L<Jr� `T' �) h, Form Approved.OMB No.2050-0039 <br /> . 5FORM HA2ARDOU3 1.GinemttorrIDDNumber 2.Page 1 of 3.Emergency Response Phone 4.Manlfeat Tracking Number WASTE MANIFEST [/ r+,4.✓u✓ /�y� `E t:.,ftU 4 ."4 �i?A"R) JJK <br /> S.Generetofs Name and Mailing Address ,ry, �,e en tpf�Sge Address(if different than mailing address) <br /> Gen <br /> ne: <br /> 6.Transponer 1 Company Name U.S.EPA ID Number <br /> FvergmenExilvilminentli CAf)%, -,24'l`3"b ' <br /> 7.Transponer 2 Company Name U.S.EPA ID Number <br /> PSC Indtsstirial t1f-dacaurr<isy , kr<�. CARM0177527 <br /> B.Designated Facility Name and Site AddressiU.S.EPA ID Number <br /> 'l5t 1..J9Y1tlAf'r�, .l�:Ml <br /> Cs�Pfi Nawlaiid}, Csriva F-irt . <br /> Fernley, NV 390M <br /> Facifi ?a Phone: 775.A5M-2760 <br /> tie, 9b.U,S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total Y2.Untt <br /> HM and Packing Group(A any)) 13.Waste Codes <br /> Na. Type Quantity WWaI. <br /> W <br /> f r' -,rv,&Yr.,f5e".-7.) p <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions andAdditlonal Information _. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the prome1hipping name,ard are dassJged,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 j`am the Primary <br /> Exporter,I certify Nat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I rhWat the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)IT am a smell quantity general r)is t a. _ <br /> Gene o Offerors PnntedrFryped Nam Signature Month Dai' Year <br /> J 16.International Shipments <br /> F <br /> ]I— <br /> Import to U.S. ❑Export from U.S. Port of enby/exit <br /> Z <br /> Transporter signature(for exports only): Date Iml U.S.: <br /> w 17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdn ped Name Signature ;'/j � Month Day Year <br /> zQ Trans 2 Pnnted7ryped Name Sig ne Month Day Year <br /> ee <br /> j18.Discrepancy -' —• <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ElPaNel Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility,(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facilllys Phone: <br /> w 18c.Signature ofAkemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated PadilytDwher or Operator.Certification of receipt of hazardous materials covered by the manifest except as,nded in Item IBe <br /> Pnnted?yped Nam'e V. Signature � \ Month Day Year <br /> `7....., O ryY [-e! - �„I ,,..lr.;n�. ,.vy_�)-r.l�,. � f/)} oC-1 0 <br /> EPA Form 870D-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />