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JK <br /> 'F MAR 1 .5 2019 <br /> ENVIRONMENTAL HEAL�.� <br /> PI-ase print or type. DEPARTMENT Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST -. ^^^7^r .+^+ ^-^ r�� ^�'� 012218831 FLE <br /> 5.Generators Name and Mailing Address Generator's Slle Address(it ditrent It!an mailing address) <br /> t„obal; thterals t,Aanagerne-l' Global Materials Management <br /> 41331 Cota Post Rd ICAO Nanh Btoadwa Aw- <br /> L-di, CA 95215 5toriclott, CA 9s21a <br /> Generators Pima: 23;:+'2-r <br /> 6.Transporter 1 Company Name U,S.EPA <br /> �IIDr�Number <br /> kA r .,al �'v!tltions '�tiLGT,4JvrKS�i <br /> 1.Transporter 2 Company Name c U.S.EPA ID Number <br /> -ff c toil �i��i��m (a\ 0 � ' NJ 015%1(b I <br /> 8.Designated Facility Name and Sile Address U.S.EPA 10 Number <br /> US ECOLOGY NEVADA. <br /> Hvry 955, 11 Miles South of&ratt)lf +'J"�'"S i DOW <br /> t?eatly, !dV SDO03 <br /> Facility's Pnone: 77&553-;e= <br /> ga 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(ifal No. Type Quantity WI.Nol <br /> cl 1' =.3077 ��l Ha2atdauzu.wasle, sali n.a.s. �LEAt), E . . <br /> 0 x -- <br /> Z 2. <br /> 3, <br /> 4. <br /> 14 Special Handling Instructions and AddilionalInformation �, -r•.•,•.., ! r`^r�rn� <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 governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the cements of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify[hal the waste minimization statement dentilied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> Gerwator'slOfferor's PrinledRyped Na Zile Month Day Year <br /> (�� 2 <br /> J 16.Intenrallicift Shipmerits Import F- ❑ port to U.S. El Export from U.S. Port of entrylexil. <br /> ? Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.TranssporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed Signature S gnature Month Day Year <br /> a ` Z 1 /9 1 <br /> Z Tran 2 Priy Name Signature Month Day Year <br /> H <br /> 2 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> M11amlest Roference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> (.) <br /> I Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility,(or Generator) <br /> a1 <br /> Z <br /> V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> D 1' � 2 3. 4, <br /> 20.Designaled Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed7Typed Name t Signature Monti! Day Year <br /> { <br /> 1-1a/1 arr n. k �-�—�-1�. 3 1 <br /> 11 n <br /> EPA Form 8706-22(Rev.12-17) Previo s editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />