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4 Please,p int or type. Form Reproved.QMI3 No.2050-OD39 <br /> UNIFORM HAZARDOUS 1.Generator i0 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number r C <br /> WASTE MANIFEST CAL 0 0 0 0 # d 1040) 424-9344 01 rJ^ ��7 6 3 14•- G <br /> 5.Generalnr s mailing Address Generators Slle Atltlress(If different than mailing address <br /> (hlik Stop Markets, Inc. L2.adiRSt okdta,.inc. 9140 <br /> 155 FL.�landers Road C 95z 4 <br /> "*stvvrQUgh, MA 01581 <br /> Generator's Phone: (SIG) 445-2202 <br /> 6.Transporter 1 Company Name U-S.EPA IO Number <br /> SELSHIpm C a►18 0 0 01 0 3 913 <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Numher <br /> t).s. ZC0109y, Nevada Cperationa N'V z 3 3 0 010 0 0 0 <br /> Highway 95, 11 iai2ee a. of Beatty <br /> "ai ttyp NV 89003 (71S) 553-2243 <br /> Fac litys Phone: <br /> 9a. 94.US.DOT Descrip5an(including Proper Shipping Name,Hazard Class,ID Number, 14,Containers 11.Total 12.Unit 13-Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity WLNat. <br /> W 1 tion--RCRA Fiazardous Banta, Solid (MG 4171) P 352 410 <br /> o <br /> (Raga, absorbent, i dill impacted vitt, <br /> � petroleum hydroCisrboil 1 c <br /> LU <br /> z z. <br /> LU <br /> c7 <br /> 3. <br /> f. <br /> • 4. <br /> 14,Special Handling Instructions and Additional Information Will" #f.L Appa0pa t~m BES I:333912 <br /> Generator is a RCRA V3QC am delis ie pl 80111 AL pRg3'RC7 <br /> 40 CPR 260.10. 0418 Cade represents y- 01t1G. QtiTISSTOiI� Cil 559237 <br /> waste that is AM Identified but not <br /> IiCRA r"014ted. PROrILIC IF 07021k 57.6 r <br /> + - 15. GENERATOR'SIOFFEROR'5 CERTIFICATION:I hereby declare that the contents of this consignment are fully and�a urately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledyplacarded,and are In all respects In proper condition for Transport according fo applicable international and national governmental regulations.If export shipment and I am the Primary f <br /> '..¢ Exporter,I certify that the Contents;of this consignment mnfo m tote terms of the attached EPAAcknowledgment eibtt5enl. <br /> I certify[hat the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or{b)'(IH am a small quantity generator)is true. <br /> Generator's0fferors Printed.rfyped Name Signature ' Month Day Year <br /> 16-Inlemational Shipments <br /> ❑Import to 11.S- ❑Export from U.S. k Port of entrylexit: <br /> w z Transporter signature(for exports only). Date leaving U.S.: <br /> - a 17.TransporlerAcknowlegnaent of Receipt of Materials <br /> Transporter 1lTYped Name Signature IN th pay Year <br /> L (n Transp❑rter 2 PnntedlTyped Name - Signature ! Month Day Year <br /> 114 4Q :g9 <br /> r <br /> y 18.Discrepancy <br /> 18a-Discrepancy Indication Space ❑Quarri ty ❑Type ❑Res ue� ❑Partial Rejection ❑Full Rejection <br /> Manifes[Reference Number <br /> 186.Alfemale Facility{or Generamr) U.S.EPA Jr)Number <br /> 0 <br /> • rai Facilil)rs Phone: <br /> �� W 18v.Signature of Allemate Facifify[or Generator] Month Day Year <br /> 19.Hazardous as Repo l Management Method Codes(i.e.,codes far hatardous waste treatment,disposal,and recycling systems) s <br /> W <br />