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or type, Form designed for t�on elite 12-pitchy typewriter.) ` <br /> •r a. =T J Er. Form Approved.OMB No.2050-0039 <br /> /ORM:HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response rare 4. nlfest Troeki Nu(m�b f <br /> WASTE MANIFEST c A R o d o , a J Bw 424-mm �� 101M ( 2 3 Jam <br /> 5.Generaws Name and Mailing Address Generator's Site Ades(ti different than mailing address) <br /> MOt1NTAIN VALLEY EXPRESS CO INC MOUNTAIN VALLEY EXPRESS CO INC <br /> PO BOX 2569 1019 BESSEMIr R DRIVE <br /> MANTECA Cil %,336 MANTECA CA 95336 <br /> Gerreratces Ptrone: U.S.EPA ID Num <br /> 6.Transporter 1 Company Name <br /> FRE11 OUW ENVIRONMENTAL SERVICES(NC G A R U O 0 1 7 1 0 9 7 <br /> i.Transporter 2 Company Marne U.S.EPA ID Nunn <br /> Sr CENTURY ENVIRONME14TAL MANAGEN4EN 1 OF C.;A C A R 0 0 Q :2 1 5 6 1 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21ST GENT IJRY ENVIRONMENTAL MANAGEMENT <br /> `495 E NBVIANDS DRIVE <br /> HERNLEY NV 89408 NVQ980895338 <br /> Facility's Phone: 7Z5 675-2760 <br /> 93, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Cis,0 NuffbK 10.Containers ers 11.Total 12 llrnt 13.Waste Codes <br /> HM and Packing Group(if arry}) <br /> No. Type Quantity Wt.l I <br /> 1. 223 HAZARDOUS WASTE.,SOLID(OILY DEBRIS, 223 <br /> ^~ <br /> ABSORBENT)LLJ <br /> a. <br /> u, _._..._....... - . <br /> ca <br /> 7 <br /> 3. <br /> 4. <br /> I <br /> %- 14. Handling Instructions and Additional Informafion 1)386168 -UIIy DeN!s ERG#1 7e°1 <br /> I'Ir17+:L'i.0tS'V0141:40fttt'I-RAW11W zV40 USE PPE. <br /> 15. GENERATOWSIOFFEROR'S CERTFICATIWI: I hereby declare that the contents of this consigrn�rt are fully and aekxxately described shave by Etre Doper shipping name,and are classified,packaged, <br /> maAked and labeled/placarded,and are in all respects in propercond'rtion for transportaccording to applk:eble intematiorial ark i)n onal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this oonsignmerd conform to flx3 terms of the alldied EPAAcknowiedgment of Consent. <br /> I cerhfy that the waste minimization stat"kWAI ed in 40 CFR 262.27(a)(if I am a large entity gena tor)or(b)(if am a small quentitty generator)is true. <br /> r Month Day Year <br /> GerreretorsfOgerors PArstedlTyped Name ! / ) �I &y' ure 1y; ,� ✓ �'' <br /> 1%kntemational Shipments ❑Import to U.S. ❑Export6'om U.S. ; Port of emryletdt: <br /> Transporter signature(for exports only): Date leav6tg U.S.: <br /> W 17.TransporterAcknowledgmerl of Recelpt of Materials <br /> Transporter 1 Prkttedffype " re Month Day Yearddar <br /> ZTra sposter2 PmtedlTyped Name Sig re/ /� Month Year <br /> q t � e <br /> 18.Discrepancy <br /> 18x.Discrepancy Indication Space ❑ Cluanlity ❑Type ❑Residr.re ❑PaNal Rejection NOVI❑Full Rejection <br /> . n( 5 RECD <br /> Manifest Reference Nunlser: <br /> 18b.Alternate Facility(or Generator) U.S:EPA IDfMint, <br /> rai Facility's Phone: -._ MotBr Day Year <br /> W 18c.Signature ofAlternate Facility(or Generator) <br /> C <br /> z <br /> 'D 19.HazeMous Waste Report Management Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. <br /> 13, 4. <br /> 20.Designated Facilityor Operator.Certification of rpt of hazardous materials covered by the manifest except d in Item 18a !1 <br /> PrintedfW Nero gnatureDay Year <br /> ...�-n�'"�.- ,_�•�;�.��r L jam' w� �� 1 !3 <br /> EPA Form 870x22(Rev.3.05) Previous edrdons are obsolete. .-. ; DESIGNATED FACILITY TO GENERATOR <br />