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Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11 Generator ID Number 2.Page 1 of 13.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I 0�3�20476 FLE <br /> 5.Generalnrs Name and Mailing Address Generators& Address(if different than mailing address) <br /> 'i E-i i It c : r <br /> IC73 :7�i! a"t 1 a E '-f0GE,v!I tt AVE y�5 E Y 0111.1EM TE A--JE <br /> Generator's Phone. 4>_ -IR :, t i --- PA ID-, <br /> 6.Transporter 1 Company Name - `h ENumber-_—;4 <br /> g-- <br /> 7.Transporter 2 Company Name _ U.S.E A 10 Number <br /> "i �,r I L iV ll - ( P�rLs1.�-. C�. I �.� J"S1'• ]yc�S� <br /> 8.Designated Facility Name and Site Address - U.S.EPA ID Number V V <br /> -`y a5 Iiir r,,;i= E BHt <br /> Fernley, NU S34138 <br /> .-Facilil rs Phone <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity 12.Unit 13.Waste Codes <br /> o „ 1�iidl-71 Wa�t� riyl�ochioritol.ttans 8. �G <br /> ERC-#ISS+ <br /> w <br /> W 2• <br /> t9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15 GENERATOR'SfOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental 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 EPAAcknowledgment of Consent. <br /> I prtify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifi am a small quantity generator)is true. <br /> [or's!t?R rs- dfB ypgd Nine ,1 � I Signa Month Day Year <br /> —'f I s� I :_. I X11 1,_ <br /> j 1 fnlemabatal5hlpmanls <br /> I-. ❑Import to U.S. ❑Export from U%, Port of e t /exit: <br /> T garter signature(for exports only) <br /> z ry <br /> D4 Ing U.S.: <br /> GC 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 !1 <br /> Transporter 1 Printed Typed Name lure Month Day Year <br /> R Anthony Mat-k IZd <br /> Z Transporter 2 Printed/Typed Name <br /> S(g re Month Day Year <br /> ':YbJ I I J <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> 18b Alternate Reference Number:ate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> FaciWs Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) year <br /> Month Day <br /> Z I I I <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1 12- 3. <br /> 4. <br /> 20-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> n i <br /> Prin YP�N � •� - <br /> at <br /> 41 C A�si �NlI X51 j`t 1 nth �E <br /> EPA Form 8700-22(Rev. 17 Previous edl ens are obsolete. D �Fl �TYTEPA s - NIFEST SYST <br /> 97+ 0-2c___!2v3 _.AL2-10072032 941053328 041379818 M PDO42219 S.D+17422 19 <br />