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111111911 mi <br /> Please.pnnI or.type,(Form designed for use on.elite(i 2-PlIch).Iypwrglturl Form Approved..OMB No.205MG39 <br /> UNIFORM HAZARDOUS i.G�neralor ID Number' 2:Page 9 of 3..Emergenw Response Phone 4.,hllantfest TrackingNumber�+ <br /> WASTE MANlFEI CAL000444057 1 (87'x) 577—f'6 ,L [J.Q . F L E <br /> 5.Generator's Name and Ma9fng Address Ganeratar's Site Address(if dlfie t than malling address) <br /> S routs#431 <br /> `(999) 999-9999 250 E Harney Ln :210 E Harney. Ln <br /> Ganerato s Rhone: <br /> Lodi,. .GA.. 95242 L Ndi, CA 95242 <br /> 5:Transposer 3 ompany. me. U,S.EPA lD Number <br /> Steric.y.cle Specialty Waste Solutions. Inc MNS000110924 <br /> 7.Transparter.2 Company Name• U.S.EPA ID Number <br /> 8.:Designated Facility Name and Site Address 21st Century , LLL U.S.EPA 1D Number <br /> 2095 New1ands Dr.. East <br /> Fernley, NV 99408 <br /> Facility's Phone: 7755752760 NVI3380835338 <br /> ga 9bi U.S_DOT Dasodoon(indirding Proper Shipping Naive,Hazard Cl ,ID Number, 10.Containers ti:Total 12.ilnit i3.Waste Codes <br /> HM and Packing Group(aany)) No, T IsQuantity MN01. <br /> X X i'UN1950,. blasts Agrasals 2. 1, E G#126 1 C 00005 R 33 Doe <br /> 0.. <br /> z.Non. .RCRA hazardous. waste., liquid (.State 2. C 00056 P 33 <br /> Repleted Products), <br /> a. on RCRR hazar nus waste, solid (State 2 00034 P 35 2. <br /> Regulated Pr.oduc.ts), :. <br /> 4: <br /> I <br /> 14.Special Handfinglnstrudonsand Addtianal.Infamatop 1.1.108 1AerDso-is,. Flampablef 2e 10844(State Regulated .Liquids <br /> 3. 1:1.0843.(Stat.e Regulated Solids) <br /> 15: GENERATpR'S1QFFicR.OR'S CER7IFiCAnaH: I herehydedare 1hat.tbe conlants of this consignment are(ally,and aorarrafely despribad 4M.by the proper shipping Hama;and are dassilfed,packaged, <br /> marked and lobi oplacarded;and am.tn all respeds in proper ca fabs r Imnsport according to appAcabileinternational and.national gin trnrnental regulations.if export shipment and I am the Primary <br /> Exporter,f.ce&`y:that ti a Contents.af tNs consignmerit conform to tie tem a of the altachad EPAAckrmledgmenl of CDANQL <br /> I csr*.ttiat the waste minim zabori.statemem identified in.40 GFR 2027 )(if€am a large quantity generator)or.(b)(11'I aj a small quanti y"%raw)is trua. <br /> s.rota yyed WarneM Day <br /> year <br /> CjQAi& A, <br /> 01i it 04 2018. <br /> --t 16,international5hfpmenls <br /> z import to U.S:. DE—mi from U:S. P of enlryfexit: <br /> — <br /> Transporter signature for exports ani Date ieavin U.S:: <br /> Cr uu <br /> 17.Transpo ierAc]aroy9edMeni of Receipt of Metarals <br /> Transporter 1 PnntMrryped Name. gna ® Month ear <br /> 0 Johnny Harper <br /> 1. 0 20 B: <br /> Transporter 2 PrintedlTyped Noma sign Monthay Year. <br /> 18.Discrepancy <br /> 18a,.Discnrpancy Indication Space <br /> ❑ Quantity Type 0 Residue ❑.Partial Rejection ❑Full Rejection <br /> Manifest Reference Numbe <br /> 18b.Alternate Faolily(or Generator) U.S,EPA ID Number <br /> C]. <br /> Fadli s Phone., <br /> w 18c:Signature ofARernate Facitiiy(orGenaratar). Month Day Year <br /> a <br /> Z . <br /> rz 19.Hazardous Wasie.Reporl Management IMEMod Codes{i:e.;codes for hazardous waste treatment,disposal,and mc:ydng.systemsl <br /> WCA <br /> 120.Dosignafed.Faatily 13vmerju.pastor:Certification of race prof hazardous. terlais covered by the manifest except as noted in Item 18a <br /> y ed Name Signet Month Day Year <br /> EPA.prm.87 -2P v.3 5] Previous editions are ahsoldte: I]E$( N1tTE :M TY TO DESTINATION STATE(IF REQUIR50 <br /> 8700-22 LEO 09289207 ,54108 173. D4185@04-0 M � PI)Ii0®ia SD110819 <br />