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i Please prim or Type.(Form designed for use on elite ch)typewriter.) ec, 1.4 -� K. 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 �;t�' .''% �i'., ..f )`I` 1 1 .. ��� ( �' d <br /> +:,.�I.c1I�f. ,:��.. .. �. B F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> MAIN S 1 KEE 1-AR4;C1 AM-PM <br /> 11.00 S.MAIN STREET <br /> MAN TECA,C:A 9tJ331 <br /> Generator's Phon . �i-r• <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i%ME:Rit:lud VALLEY WAS C-(AL, INC. CAFtRW212302 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> f-(,IALIY WAS'll F. SOI_)TIOI%IS, INC MN8000110924 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21,,i LA:--NIUNY E:NVIRONMENIAL MGMI QU NEVADA,LL(; Rfl/E�c9f�f1E{�53i8 <br /> 2095 NE WL.ANDS DR.EAST <br /> F:ERNLEY,NV 139401) <br /> Facility's Phone, It,, • 1 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> I 1• <br /> l p ItO I`IA:107'/ MA.7ARI)(A F;VJiIP,STF= S(11#1,N 0 S,.L, sac;Nl.(WO!It 1! 150 D018 352 <br /> I, <br /> N:DIF-SFl (A JIVIP F-11 TF RS R HOF,FF- <br /> w <br /> i z 2. <br /> LU <br /> RECEIVE6 <br /> 3. AUG 15 2018 -- <br /> 4. PERMIT/SERVICES <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> f'ROFILE# 791370-01 ABSORBENT,HOSES;GAS I RG#171 <br /> FMERGENCY CONTACT: JA SBIR <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a,small quantity generator)is true. <br /> GeneraloeslOfferor's Printedffyped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> j! W 17.Transporter Acknowledgment of Receipt of Materials ,r _ _ <br /> FSi lure Month Da Year <br /> Tran ��j Priv d/Typed ame Y <br /> - <br /> z Tr aV2 Pri tedryped N ' / _-.Signature onth Day Yeaf <br /> 18.Discrepancy <br /> ( 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Refer 21st CEM of Nevada <br /> I' <br /> 18b.Alternate Facility(or Generator) <br /> for and will accept the waste <br /> J <br /> athis gen rator is shipping. <br /> LL Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z _ _ <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,dispose71Rtl Ncycling systems) <br /> LLI 1. Z. 3. 4. <br /> 14 1"T1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exce Ge noted in Item 18a <br /> I: Printed/Typed Name Signatur `� Mo/nth Day Year <br /> ` EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> / DESIGNATED FACILITY TO GENERATOR <br />