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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form ADDroved. OMB No. 2050.0039 <br />r=r„rormorvv-zttnev. 5-111, rrevlouseamonsamoosolete. DGSIGNAKED FACILITYTO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />Mantfeat Tracking Number <br />WASTE MANIFEST <br />CAL000t37 63 <br />1. <br />; 8771 5 7 7--2659 <br />000039844 DAT <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />rRN MQUIN OICPORT Slip JOFR)UIN AIRPORT <br />5001; PURPORT WY 51100 AIRPORT URT <br />Generator's Phone: STOCK -a is Rug; L791454 ri2ra STUrt104 CR 95206 1'2119AH-4720 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st Gentury 'Env l r Orlllien _31 M2'' ageiiwn t of i til f{ rnia, L.P CIRR000210617 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />—SZ -7-&_ 0,9's-zo ` V - <br />a. Designated Facility Name and Site Address U.S. EPA ID Number <br />SYSTECH ERYIROMB-1 1 - <br />loo wa CENEw ROOD <br />Facility's Phone: FREDON10, Ys W36 iUa) 376-401 KSD980333259 <br />ga <br />gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if arty)) <br />Quantity <br />NRNoI. <br />1. ill3lM ILMM iL[ i- 4UTAD, pUS tlti Ir'LOIOL, Dwcm 3 F61I7-1 <br />z73 <br />3r)5 <br />H <br />10401 <br />Z <br />LU <br />2 J?e;"I@T RFLOTD OrT ERi?>� Rlhr S, TOWERS) 3 P611 <br />,�� <br />3g <br />a. <br />D� <br />�1b� <br />I3 <br />3. <br />— <br />;v <br />+ <br />4. <br />AU <br />2 2 <br />.014 <br />14. Special Handling Instructions andAddtional Information y <br />;) nAH320-00w %f l 1§1'1(�UE [2) BEl.'•OIM-91 - LRo1127) ?,ULN OIL ME PRINT, IDEPAR- MEN-;_ <br />ilt1R0LBr <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this corsignment are fully and accurately described above by the proper shipping name, aril are classified, packaged, <br />marked aril labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national govemmental 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 EPAAcknovAedgment of Consent <br />I certify that the waste rnmimization statement Identlfled in 40 CFR 26227(a) (if 1 am a large quantity genera)" (b) (if I am a small quantity generator) is true. <br />Generatoes/Offeroes PbntedlTyped Name Sign re Month Day Year <br />s.'T Cf <br />_j 116. <br />Intemational Shipments <br />❑ Imoort to U.S. ❑ Export from U.S. Port of antry/axit <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />U= <br />17. Transporter AdmWedgment of Receipt of Materials <br />~ <br />S' e Month .Dya�y.� Year <br />Tra er 1 PI tedr" N A r <br />. <br />Z <br />Transpo ter 2 Pdn 'ped Name Signature Month Day Year <br />'•- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Reiection ❑ Fun Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />Facirdy's Phone: <br />LU <br />t8c. Signature of Allemate Facility (or Generator) <br />Month Day Year <br />IF - <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1T:01 <br />2. <br />13. <br />4. <br />20. Designated FsO ty Operor Operator. Certification of receipt XaZarclous materiels covered by the manifests wnoted In Item 18a <br />dntedlTyped Name Sign Day Year <br />4 P".r <br />r=r„rormorvv-zttnev. 5-111, rrevlouseamonsamoosolete. DGSIGNAKED FACILITYTO DESTINATION STATE (IF REQUIRED) <br />