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use <br /> Please pont or type.(Porto designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050M39 <br /> 1Go uID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> . <br /> UNIFORM HAZARDOUS i 1 `.! 00u26669 SKS <br /> WASTE MANIFEST L -901"i 4i;R-176G <br /> 5.Ceneretors Name and Mailing Address Generatcrs Site Address(if dMerent Man mailing address) <br /> LTEC BRAVE CYSTEM: <br /> PlICY ;.AAIf. CA 9520t <br /> Generatoes Phone:2 U 9-9 8 2-1.8!C <br /> U.S.EPA ID Number�RTTXR000050930 I�"'V;TEM •, iNt <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address p c UOLOGY NEVADA 0505ti5 U.S.EPA ID Number <br /> 1114ILES S. HWY 95 <br /> BEATTY NV 141i0!13 <br /> 775-553-22:" NVT33001000U <br /> Facility's Phone'. <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 1D.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(Many)) No. Type Quantity WtNal. <br /> N RUkA-HMARDOUS WAS'TF_ H lt)I _. __.. ._ F ONE 22 � <br /> o IL>' PIT SLCrDGF -A-N( WXTr <br /> z IoN RCRA HALAPI.`i)$ 'WASTE LIy''LIDo 'M C' NnNE 4: <br /> AQUEOUS PAINT WASTE ! <br /> r <br /> 3. <br /> 4 x. Y <br /> 14.Spedal Handling lnstrucbons andAdditional Information 3V TRCK#10J85 I 0I tI : <br /> i' <br /> S A'1TtT?NI2ED TO RETAIN L1.' ENSEli l'F,FrQUlr. T ChftP.4ERS AS NECE4SARY <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this vnsignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respells 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimisation statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(AI am a small quantity generator)is We. <br /> Generator'slOSeror's Pnnledrryped Name Sgpeture Month Day Year <br /> V- / <br /> i6.International Shipments ❑Import to U.S. ❑Export firm U.S. Port of entry/exit: <br /> = Transporter signature(for exports only). Date leaving U.S.: <br /> W 17.TmnspvWAclawxledgment of Recall of Materials <br /> 7ranspmrle'1 Printedrfyped Name Signature Month Day Year <br /> a - <br /> QTransporter 2 Pdnted/Typed Name Signage Month Day Year <br /> K <br /> H <br /> r18.Discrepancy <br /> 18a.Discrepancy Indication Space El 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 /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate radial(or Generator) Month Day Yea' <br /> a _ <br /> z <br /> H19.-Hazardous Waste Report Management Metod Codes(i.e.,codes for halal waste mean nent,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Fadlay Owner or Operator:Certification of receipt of harardous materials mveml by the manifest except as noted In Item lea <br /> illi Print yped Name Signature Mont ay Year <br /> TEPA fgpg87jjI422(Rev.�.-95A•Prevjops allows are obsolete. ,( I GENERATOR'S INITIAL COPY <br /> iJ ; 491C,31- 5a <br />