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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) i Form Approved.OMB No.2050-0039 <br /> UNIFORM HAL—w t)5 1.Generawr 1D Number 2.Page 1 of 3.Emergency Resmnse Pfhono4.Manifes!TTrackin Number }� <br /> WASTE MANIFEST CALOOD39lt071 (1177) 5?7--26F-1 Q0 U 1�J.810 DAT <br /> S.GeZatofs Name and Mailing AeAddress Generator's Site Address(if dift mrtl than mating address) <br /> fie LOTS STORES 116 LOTS 14512 <br /> 308 pRIL1_IP R1I ATTR: 0EI41 FIRM 1321 VEST TOVITE RYR- g- <br /> Generalor'sPtahe: 41Lf6f11R)S 437,78 (6102T8 W4 KiELt#TFCR £A 35331 <br /> 6.Trarhs7 o ter t CampadY Name U.S.EPA IC Number <br /> STF-RTCY4:LE SPECIALTY UASTE SOLUTIOMS INC NNSf 0011QS2ts- <br /> 7.Transporter 2 Company U.S.EPA 10 Number <br /> e, ��—/—q-"/ <br /> peslgrhated f=acility Name and SdeAddr s U.S.EPA i0 Number <br /> 21ST calf FY." ENVIR RKEML 9O hE((T OF RMEH, LLC <br /> 2gg5 Neulands Drive Eau# <br /> FaczR sPlrane: FERNLEY, KV 91490 (715) 575-2111 Nvbg nAqRq-"lf4 <br /> 9a. 9b,V-S.DOT Des*lion(In6dding Proper Shipping Name,iia[a d Class,ID NumW 10.Containers 11.Total 12.Unit <br /> 13.waste Codes <br /> RM aeAPatdting croup('d any)) No. Type Quantity WtN01- <br /> 1. URIM WSTE AEROSOLS 2.1 17011891=363#T 331 D681 <br /> 3. <br /> i4i, 4W <br /> 4. (fM13R3 tjFTE FLfMMj4D(.E !I TI1�, N.O_S. VEROURE, DIESEL 3 P611f ) 331 1681 RDSS <br /> !Y!{ R6Q? D618 D835 <br /> 14.Special 3iandling Instrmfions and Addltional lnfomtalion <br /> 113 1LFEROSOLS-03 - ERVIN) AEROSOLS <br /> Mt BeR*SfVF+W M KFLWIQ-53 - WWI) FLf1WILE LI0U1B <br /> 15. GENEMSOWSIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and awirately desmbed above bytiu:proper shipping name,and are classified,'packaged, <br /> marked and tabetedfptaearded,arm are hr ail rmpects In prapar cendbon for transport aocardingto applicelhe fntemationsland national govemmentai mrguialions.Iiexport sWpmwI and I am the Pdmary <br /> Exporter.i cerfifyW the contents of this nonsignment conimm to iha terms ofthe attached EPAAcknvwledgment of Consent. <br /> I car€ity that the waste nvahrhization statoment Identified in AD GFR 262.27(a)(it I am a large quantityganamicr)or(b)(it l am a small quarfityganarator)is true. <br /> Generalvt'slOiferols Phi adiTgped� r= Signal Mo h Day- Year <br /> 16.International Shipmenls <br /> F- ❑impart to U.S. Earp d fro - - Port of mloexil: All <br /> — <br /> z Tramsporter signature(for exports only): Date leaving U.S.: <br /> 17,Transpohtar Acknowledgment of Recaipt of Materials <br /> TranspoUr 1 NntedRypedName f` Signature lvion Day Year <br /> E/l�yv[ <br /> 4 TrdRS erg dff d Na / SigneNre Month ay �r <br /> re <br /> 18.Dwepancy <br /> 188.Discrepancy Indicalion Space ❑ quantity ❑Type ❑RaSIdue <br /> Partial t2e,Iecl6on ❑Full RejecBan <br /> Manrfaslfteterence Number. <br /> 18b.Alternate Fadfrty(ar Generator) US.EPA ID Number <br /> FacliEy'sPhcne: <br /> r it c.S€gnature of Wremate Fadite(rs Genarainr) = Month ay ycar <br /> Q <br /> z <br /> i9.tdazardous Waste Management Method Codes(i.e..codas for hazardous waste treatment,dsposal,and recycling systems) <br /> p 1. 2, 3. 4. r <br /> 20.0esignateff Facility Owner or Operator:Cedifoagon of receipt of hazardous materials covered by the manifest except as noted In Item 18a jf <br /> PdnW[Typed Name 5ignamra n e <br /> EPA Form 9700-22(Rev.3.05) Previous editions arenbsOete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />