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ed for use on elite 12• ' er. ` Form Approved.OMB No.2050.0031 <br /> [�Please prim of type.(Forth design ( pkh)49eWm ) <br /> UNIFORM HAZARDOUS 1-General%ID Number 2.Page 1 of 3.Emergency Response Phcne t.MarifoatTumber <br /> WASTE MANIFEST C,AL0001965M 2 8oaa2�-s�oo CI�E�rREC 006'H8400 JJ K <br /> 5.Generalofs Name and Madrg Ad Gemiatoes site Address(d different than mailing address) <br /> RANNON TIRE CLAREMONT 4905 CLAREMONT AVENUE <br /> 2.0.BOX 1988 STOCKTON,CA 95207 <br /> OCKTON,CA 95201 <br /> Generator's Phon?09-477-9000 <br /> 6.Transporter 1 Carnparry Name U.S.EPA ID Number <br /> FR ENVIRONMENTAL SERVICES INC CAROW171017 <br /> 7.Tra,sperter 2 Company Name U.S.EPA ID Number <br /> 21 ST CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA LLC CAR000164012 <br /> 8.Des gnated Faddy Name and Ste Address U.S-EPA ID Number <br /> 21ST CENTURY ENVIRONMENTAL MANAGEMENT INC ►.IVD980895338 <br /> 2095 E.NEWLANDS DRIVE <br /> FERNLEY,NV 89408 <br /> Facirty's Phcre775-575-2760 _ <br /> ga 9:U.5 DOT Description(incl g Proper Shipp nc Name,Hazard Gass,tD Plumber, 10.Containers 11.Total 12 Unit 13 Waste Codes <br /> H;1 a-d Pza og G-aj.2 Ceaoy; No. Type Ouantty N.1.Not. <br /> Norr-RCRA Hardo Waste Solid(Brake Shavings) -R� P <br /> nt�Z� <br /> o - <br /> z 2 <br /> W _ <br /> 3 j I <br /> 1 ! <br /> 4. <br /> 14.Special Haring I ahx:bccrts and al Information <br /> Handers to be 40hr t18I and use ppe. <br /> 9b 1)388096.01 �Z, ERGC 71 <br /> 15 GENERATORWOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignuwt are"y and a--tely desaibed above by the proper shipping name,and are classified,packaged, <br /> marked and ebeiedlplaraded,and are in al respects in proper condition for transport according b applicable international an/n:i/� <br /> tai regulations.U export shipment and I am the Pfinary <br /> Exporter,I certiy that the contents of this consignment conform to ttre terms of the attached EPAAdcnaAedgmem of Consent <br /> Ice"bit the waste minunizatior.Statement identified in 40 CFR 26227(a)(d I am a tlge quantity generator)a(b' '1 amantity s true. <br /> Gene f tfeTOfs Prinled(Typed Name a Mwttt Day Year <br /> r N D <br /> lm�"— 17 <br /> 16.Inrational Smens <br /> fig <br /> F ❑Import to U.S. ❑Export hA U.S. ort P <br /> z Transporter signature(for exports onlY) to 1 ving U.S.: <br /> W17.Ttaraporter Ac4t-- edgrtent of Remi of Materials <br /> Transporter 1 Pm teedTyped 5 Month Day Year <br /> O <br /> a rl it, <br /> z Tr 2 Pr nttd Typed Name S'na r Month Day Year <br /> Q <br /> � O <br /> t- <br /> 1 Di ncy <br /> I Sa.Disaepaney Indication Space Quantity ❑Type Residue ❑Partial Rejection ❑Fd Rajecbort <br /> Manifest Rekm4xe Number <br /> 111.h;A1>ErrratP Facility(Or GEtlrXatOt):-`«-n _n. _•. ar:hear•ast `+�-y;a.+ _e:-.x�- ..,. .. :rte,. ,.tV.S.EPA ID NImbN ---•'r"!•". <br /> _J <br /> LL FadWs Phone <br /> a18c.Sigrtatrue of Alternate Faddy for Ger% tor) Moth Day Year <br /> Q <br /> Z <br /> rn <br /> 19-Hazardous`Vaste Report Management Method Codas(i.e.,codes W hazardous waste treatment,disposal,and recytdirtg systerns) <br /> W 1 2. 3 4. <br /> =} ISI <br /> 20.Desynated Facility Owner cr Operatcr•Certification of receipt of hazardous materials covered by the manifest except as hared in Item 18a <br /> PrintedlTyped Nome ( �i Signature klo� Day Year <br /> EPA Form 87010-22(Rev.3-05) Previous edtions are obsolete. DESIGNATED FAIIII ITY TO DESTINATION STATE(IF REQUIRED) <br /> ",n M. "WIF c"NAc AkTa arinw-�mj RfCFif`Qti7lnlT YVA tt:trT TT07./F7./R0 <br />