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for. 7-995("Ar
<br /> Please print ortype'!r Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number n
<br /> WASTE MANIFEST t+a oct!iCx 7rtict'� E 87!'} 577-266, 002 W O G DAT
<br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address))
<br /> CITY RN1 M-11 Y OF SHIM I811CY FKILITY CITY W CGURTY OF. SF•-PUC T61 Y FACILITY �
<br /> 1390 MYSEY STRU-1. STU"71. 9901 VEST VERA11S !tom
<br /> Generator's Phone: SIMFRR>% ISCO C9 94112 (4151253.-3977 MQ,CA 95371 �
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> SIERICYCLE SPECIALTY WASTE SOLUTIONS.:INC MNS000 II3q24
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> B.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> 21ST M(MY Elr'ttl10WTX RN MEAT Of NLYA111, LLC
<br /> 2195- a113ds Drive Fast
<br /> Facility's Phone, 8114 EY, VV 89401 (.d15)-375'2759 ' . MVDB€IOB,9633$
<br /> ga: 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit
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<br /> and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Code '
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<br /> 14.Special Handling Instructions and Additional Information
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<br /> 15. GENERATOR'SlOFFEROR'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 Iabeledlplacarded,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 t6theterms of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)jif I am a small ua�igty generator)is true.
<br /> Generators/Offeror',PrQtTylied Name Signature M fDay e
<br /> 1
<br /> 16 International ShilTments n� '1j.9' M1,,
<br /> t• i= ;� .. r t"k only4 L to U$ �1�it i' r*Q Expbtt frpm �.. r Polt of entry(exft
<br /> z' Transporter signature'(fsl ;.,+ �r r
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<br /> ad' 17 Trans'po kt cknoledgmbntpfIRet6lptluu
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<br /> .Tra sporter 1 PnntedRYp� leh. 3 '`� •v . ,*"" 'A, + rtr �+tj' 6 a rh�t - �""' ttxi Da Year 9?,
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<br /> Trans 'er2 dgted[Typed Name Si ++� :.
<br /> 9Month lraY Year i
<br /> 8.Discrepancy
<br /> 18a.Discrepancy Indication Space
<br /> ❑ Quantity Ll Type ❑Residue' ❑Partial Rejection El Full Rejection
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<br /> 18b.Alternate Facility(or Generator) -S t AID Number
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<br /> Facilitys Phone:
<br /> has the appropriate permits s)
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<br /> W lac.Signature 4f Alternate Facility.(or Generator) for, arid V111 Month Days.. Year'
<br /> a. +his generator is shipping•
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<br /> 19 f(azardous Waste'Re qrt Management Method Codes�(Le codasfor hazardous waste,treatment dis osal, I tec 61- s tem$
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<br /> 20 Desigat d Facility:Owner or D.perator.Certiflcahon of.receipt of'tiazardous materials covered by the Manlfes ezcepf as noted in Item 118a ,,;; �' v
<br /> PrinteclTT e ` r, 5a. ,
<br /> YP Na (( f `t., Signa a ,r•.- - on
<br /> ay Year.
<br /> EPA Form 870.0-27 Rev:12-17) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR
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