Laserfiche WebLink
y <br /> Please print or type.(Form designed for use on elite(12-pitch)rypewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 1 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking <br /> �Number <br /> UNIFORM HAZARDOUS 966-333-0222 0 Q .1,9l1 1586 FLE <br /> WASTE MANIFEST s^_.dil7�k gr��p���p <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 4 ox-n Pcaalcect,',R S.retaarn; ti anal Inn 10211 Ixtt'lalttil l or <br /> P.o PWAX 61:29 $Cclnhtsan. Gan 95d0� <br /> attw.ktun, Ca 95246 <br /> Generators Phone: 20,q §R2-1920 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> Advanued clxsYF ica l. g'Y te_ C>4" 'L'; i 4'* ria, <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> M Itde lox Nevada. lana <br /> P-r3 WX �B, HWY 95, 11 ll 13. 84battr:f <br /> Be tty, NV 69045 <br /> Facility's Phone: 8043-2.19-3-443 14 V06a <br /> ga 9b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Parting Group(if any)) No. Type Overtly Wt.Nol. <br /> 1.Won RCBRA iRaxalc4wiiiia itasil sillid <br /> x <br /> z 2. <br /> W <br /> f7 <br /> 3. <br /> 4. <br /> 14.Special Handling lasWctlons and Additional Info prion _ <br /> 1) ICuu- ) It P �{It .6 ✓rl <br /> PV*1*4t WwNh r' CV02, S-02 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this 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 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(x)(if I am a large quandly generator)or(b)(it I am a small quantity generator)is We. <br /> Gen rator erors PmdedlType Name igna ure ,J, on ay ear <br /> 16 International Shipments ❑ <br /> i- Import to U.S. ❑Exportfrom U.S. ortofe'ntryle <br /> Transporter signature for exports only): Date leaving U.S.: <br /> w 17.TransporterAcknovdedgment of Receipt of Materials <br /> oThan o er1 do[ yped Name i9naW / on ay Year <br /> Q Transportr Prnted/Typed Name ignanum Month Day Year <br /> K <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Oumli Type Residue <br /> ty, Elyp ❑ ❑Parfial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL adli 's Phone: <br /> W18c.Signa ofAlternate Factlity(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manBest except as noted In Item 18a <br /> PrintadRyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />