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1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) WO 4:r -7 ! J ! Form Approved.OMB No.2050-0039 <br /> } UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST - 0 0 6^u 6 8 5 6 8 JJ K <br /> 5.Generator's Name and MA.MAddress 0eneiafors Site Address(if differentN mailing address) <br /> lern�l� �\a� <br /> 40o W. Jo��p.co <br /> Generators Phone: <br /> 6.Transporter i Company Name I ItU.S.EPA ID Number <br /> FREMOLPVV ENVIRONMENTAL SERVICES INC F1pne*800.551}3274 CAR000171017 <br /> 7.Transporter 2 Company Name U.S.EPA IO Number <br /> 21 sit CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA,LLC CAR000164012 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21 ST CENTIMY EMI <br /> 2095NE11YI.ANDSDRIVE EAST NVI:19801885938 <br /> FERNLEY,NV 80408 <br /> Fatal' s phme:775-575.278D <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ContainersType 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Quantity WLIVoI. <br /> 1. Non-RCRA Haravdcnds Nlaste Solid(Oily Debri DM P 223 <br /> i 2. <br /> W <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Harmers to be 401v trained and use PPE. <br /> 9b1)38818&00 ERG*171 <br /> Y,<v<- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents o s consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelecilplacarded,and are In all respects in proper condition for transport according to applicable International and national govemmentsl 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 L ;' <br /> certify that the waste minimization statement identified In 40 CFR 262.27(x)(it I am a large quantity generator)or(b)(dl a s nifty go r)is true. <br /> ereors/ORerors Printedrryped Name Signature Mlonth Day Year <br /> 1011169 <br /> 16.Intematio Shipments <br /> F Import U.S. ❑Fxpod from U.S. Port ofeniry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknoMedgment of Receipt of Materials <br /> 2 Tranapor 1 Printedrryped Sig Month Day Year <br /> 10-11001 <br /> N ` d101a Transporter 2 Ptinted/Typed Name _ Si re Month Day Year <br /> i1 .Discrepancy -- <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type Residue ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rat Facitity's Phone: <br /> Maj 18c.Signore of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> S2 19.HaimmDUS Waste Report Management Method Codes(i.e.,codes or ha ramous waste treatment,disposal,and recycling systems) <br /> W 7. 2. 3. 4. <br /> 20.Designated Facility Owner or OpereNr.Certification of receipt of hazardous materials covered by the manifest except a noted in Item 18a <br /> Pdnted/Typed Name Signature IMonth Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> 10-19-09A013:59 RCVD DESIGNATED FACILITY TO GENERATOR <br />