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Please print tar pe: Form Approved,OMB No.2050.0039.; <br /> [1NIFflR111.HAZARpCtl38. 1 Generator fp Number 2.Page 1 of .3.Emergency Response Pho a 4.Manifest Tracking Number <br /> WASTE MANIFEST Cp#�000440057' 1 t8.77a. X77-2 69 013656996 FLE <br /> 5::Generators Name and Mailing Address. Generator's Slte Address(if di rant Ihan mailing address) <br /> promt.s#431 <br /> (.959:) 999-9999 250 E Harney Lig 50 E: Harney Ln <br /> Generalorsf?hone-. Lt3di., Cil 95242 1 >ad1i CA 95242 <br /> 6.Transponer1 Comparry Name 11.5.EPA 10 Number <br /> Stericycle Specialty Lias I? Solutions Inc MNS0100110924 <br /> 7:Transporter 2 Company Name U.S,EPA ID.Number <br /> 8;Designated.Facility Nana ar d Sib AddrlrSs <br /> elst Century , LLG U.S.EPA ID Number <br /> 20.95 New l an s Dr. East <br /> Fernley, HV 89408 <br /> Facility s Phone: 7755752760IV V 71980995338 <br /> ga. 8b..11.5,DOT Description[including Proper Shipping Name;Hazard lass,ID Number, 10:Containers f 1.Total 12.iJhi; <br /> HM and Packing Grovp(if arty)] 13.Waste Codes <br /> No. Quant fy WI,%f.. <br /> o €X �` N1950, Waste Perosols 2. 1, RG#126 1 F O001 P 33 7100 <br /> z 2: <br /> LU <br /> COD <br /> s. <br /> 4.: <br /> F <br /> 14.Special Handling lostrudons andAddiffonal lnlormation 4 P t?r.f]5 415, Flammable) <br /> 75. GENEltATDR'SIOFFERQR'3 CERTiF1CdT.IC#;1 liareby dedara that It a conlents of this comigntmrit are fully and aocum*.describet above by the.Proper shipping name;anc.are dassifed,packaged, <br /> marked and labaledlpfacardedi and are its W1 respects in proper condNor for transport accurdfro to applicable international and national g mental regulations.If export shipment and 1 am the:primary <br /> Exporter,I cartifyy that the cmwrit5 of this c0"gnment conform to the 1w hs of the attached EPA Aeknowof C en <br /> I Certifyfhaf the waste mininikation statemer deet Fred in 413.C.FR 782. (a)cif I am a Targe quantity genledgmerd Wdgmerd E(f I m a small ty.generatorl s true: <br /> [&1. is pdntedlPYPed Name <br /> Month pay Year <br /> „j 16.Intemalional Shipments 1 <br /> f- ❑Importto U.S.: ❑Export front U.S. Port of eolrylexft. <br /> 7ransportersignature[fa experts only)' <br /> Date le6ing U.S; <br /> W 17,Transportar Acknowfadgmenl of Recafpt Of Materials <br /> LU <br /> F-- Transparler 1 Printed Typed Name Month pay Year <br /> tom. 5nature <br /> T Johne Harper 0 1 20 9 <br /> .ransporter 2 Prime <br /> FFdrryped Fame Slgnahue Month Day Year <br /> I— f 4 <br /> 18..Disorepaitcy. <br /> l a,Disbrepan4 ridication Space. 4uantity ❑Typo <br /> ❑Rasfdue ❑partial Refection ❑Fun Rejtecfion <br /> Mariffes!Reference.NumbE <br /> F 18b-ARemate Facility{or Genaratpr} <br /> U,S.EPA ID Number <br /> J_ <br /> [J <br /> LL FkhVs Ph.11– <br /> LOU <br /> 16.c.$ignatuFe of Alto <br /> mate Facility{or Generator} Month pay Year. <br /> Q <br /> 1$.Hazardous Taste Report ManagemeN.Method Codes(i.e.,codes for hazar Jous waste Watment,.disposa(and recycling systems) <br /> LU3. <br /> to 1.. 11 i�r 41 <br /> 14 7 q- <br /> 20,Designated Facility Ownsr of opemWr:.Cert ficauon of receipt of hazardous rnatarWs covered by the manlfesf except as noted is liem 18a <br /> PrinledrTyped Name S gnalure. j Month Day Year <br /> FPA Farm 8700 22.:(Rev:72=17) Previous editions ars obsolete; rjnf� ED FACILITY TO EPA's e-! ANIFE5T SYSTEM <br /> 8700-22: 12Y3 08285207 <br /> 941087173 041512095 tri PD0812.19 57108.1219 `` <br />