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- � 1�1111111NI1111111NNIII�I�I�IIININIIIIII�N�IN� Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 1 I B 7 7 5 7 72s:69 011385159 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) "'094787726 5406 Pacific Avenue 5406 Pacific Avenue Generator's Phone: Stockton, CA 9521217 Stockton. CA 95207 6.Transporter 1 Company Name U.S.EPA ID Number 6teViCYCle S - ialty i.la=te �=ciutirfn Int' 144SO00110g2j 7.Transporter 2 Company Name �31 U.S;4; ber ,�4 8.Designated Facility Name and Site Address 21st Century EMN, LU.S.U.S��EPA ID Number 209'5 Newlano_= lit-. Ei=-t Fernley, NV 89408 Facility's Phone: 1'7,j 5"752760 NVD9B t`-r95 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. X 1UN1950, baste Aerosols, Flammable, (Methyl 1 nF 00002 r 331; x;001 D005 0 Ethyl Ketone) . 2. 1. ERG#12E uu 0007 r DJ035 Z 2. W R 3. 4. i 14.Special Handling Instructions and Additional Information 1. 10356E(Aerosols Loosepack; 15, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described aboveb e proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govern fal regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 91,fokent, I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)o b)(if I am a small i generator)is true. en tor's/Offeror's rinted/1ypedName Signature t:Jneha tC0 ont ay ear J 912 1 i0 16 201' J 16.International Shipments Z1:1Import to U.S. ElExport from U.S. Port of entry/e3'. Transporter signature for exports only): Dat avin .S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name ignatur Month Day Year a. Anthony Mack zz Transporter 2 Printedfryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Q I Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. I 2. 3. 4. 20.Designated Facility Owner or Operator:Cerfiflcation of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signatu Month Day Year EPA Form 8 00-22(Rev.3-05) Previous editions are obsolet \ y GNATED FACILITY TO DESTINATION STA? (iF REQUIRED) 8700-22g12v3 08269796 S41004817 041228991 N PD101618 0101618