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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM NAL4RDOUS 1.Generator ID NumberLl <br /> T! <br /> oT 3,Ernergenry Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ,, 4 V 5 FLE <br /> 5. me neratara Naan Mailing AiTO `i'` F,enerator's'S res5( different than mailing address.) <br /> Mwdeca ikttfied Schr<,l U Dori (Stena lids) <br /> 17M Thmas St <br /> Generators Aon 955337 <br /> IT rarwporter I Coariparry Rift <br /> a <br /> 1t U.S.EPA ID Number r�yy� n <br /> A-�'.i61f'Y..&d C.. w ll�.a711 Tract,Part 1rIi:.?�A AC ERM0 �00007� 540 <br /> 7.Transporter 2 Company Name U,S.EPA ID Number <br /> E Designated Facility Name and heAftm U.S.EPA ID Number <br /> 95 S Raatt r 9 ,11 L <br /> t:u#agy Nevada i�c N1lT,1.s�S r 1 <br /> Byyox 54 <br /> FlD td <br /> FaciraBlm�ft Phoma —7r � ,a <br /> Sa, gb.U.S.DOT Description(indudirg Proper Shipping Name,Hazard Class,ID Number, 1 C-Containers 11.Total 12.Unit . <br /> HM and Packing Group(if any)) 13Waste Codes <br /> 1MiNe. Type Quantity Nal. <br /> Cr L <br /> M A i08l. l iai:rrcl a u'�.rr;.liquid.rt.r�,., (PhciOn Shw--r f <br /> a i Sr"err) 9 P6111 <br /> r <br /> Z z. <br /> ru <br /> 4. <br /> 14.Special Handling Insbvctions and Additional Inlonnatl0n <br /> I'"W-r NuMbOr UmUlft"It 4. 019743:. <br /> 1)ERG#171; 07013775N271 MAH <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedaro that the contents of this consignment are fully and accuratety described above by the proper shipping name,and are classified,packaged. <br /> marked and Iabeiedlplararded,and are in all respects in proper condition for transport according to applicable international and national governmental regu ations.if export shipment and I am the Primary <br /> Exporter,I certify that cite 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 262.21(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is tnie. <br /> neraW eros PnrtWffyped Name Signature Month Uay ear <br /> 16.International Shipments <br /> �— ❑Import 10 U.S, ❑Export from U.S. Port of entryletdt <br /> Transporter signature for exports only): <br /> Date leaving U.S.: <br /> u.t <br /> 17.TransporterAcknowledgment of Receipt of Materials �, f <br /> Tran er,1 proot d Name 1 lens re on ay, ear <br /> 1 i Q'I ; - _ , i ;> ,(�' i J, <br /> 1 " <br /> d Transporter PrintedfTypad Name ignature onth Day Year <br /> H <br /> 18.Discrepancy <br /> 19a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b A temate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> Facility's Phone: <br /> C3 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 1 <br /> rnQ.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,,din <br /> pons'.and recycling systems) <br /> 2. 3. 4. <br /> 2:_Designated Faciiily Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Bern 1 Ba <br /> ;'7nted'IypedName Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edifions are obsolete. GENERATOR'S INMAL COPY <br />