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P'^ase print or type. /Y n 4$pIpve4,QM3 No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mani esrw umb <br /> WASTE MANIFEST - �nrr+�, + r�� ���� 01Z` FILE <br /> �i!• <br /> 5.Generator's Name and Mailing Address Grrneratar's Slle Address(if different Oran mailing address) <br /> taar,13,3! tv;ateriaas, GlobaMaterials fhnagen�-;1' <br /> 4931 Cota Post Rd 1640 Orth Broad wa AV-- <br /> CA <br /> vcCA DZ:215 StocAlon, CA 95215 <br /> Generators Phorie: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> .lLtItvis n <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> T� c cn c� fnv"ccf��na�ca� � ,, t MI)a$%%%1 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US ECOLOGY NEVADA <br /> Mary 95, 11 Miles South of Beatty NVr,"'-, " <br /> atty, NV WW3rr, <br /> Facility's Phone: 77JrZa-=- <br /> ga 91b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13 Waste Codes <br /> HM and Packing Group('d any)) No. Type Quantity WI.NoI <br /> Qom. 1.NA30 Vl- Haaard::U--wa5ie. sso�iud, "LE-AW, i. Ii, 131 <br /> DOW <br /> Z 2. <br /> UJ <br /> c9 <br /> 3 <br /> 4. <br /> 14 Special Handling Instructions and Additional Information ��Of:1r1113t1t D2SSE-41 <br /> rn—Al „ <br /> 15. GENERATOR'S10FFEROR'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 governmental 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 certify that the waste minimization statement identified in 40 CFR 262.271a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneraloeslOOeror's Printed7Typed Na Sign re Montt Day Year <br /> I. \IA� <br /> G� <br /> J 16.Intemat' Sh' <br /> 1— ❑Import to U.S El Export from U.S. Port of entrylexit: _ <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> Q 17.Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a <br /> ZQQ Trans 2 Pd y d Name Sgreture Month Day Year <br /> a� 2 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facllltys Phone: <br /> W erator)18c.Signature of Alternate Facility(or GenMonth Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1, � 2 3 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 /> Printed/Typed Name Signature Mont Day Year <br /> EPA Form 8706-22(Rev.12-17) Previo s editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />