|
Please print or type, Form Approved,OMB No,2050.0039 .
<br /> UNIFORM HAZARDOUS 1,Generator ID Number 2,Page 1 of 3,Emergency Response Phone 4,Manifest Tricking Number
<br /> WASTE MANIFEST A y 0 0 0OA3341 i 1000) 424-9300 FLE
<br /> 6,Generator's Name and Melling Address Generetore Site Address(If different then melling address)
<br /> Qui.k .Stop Harkets, Tnr;:; jiikk �t Markets, Inc. 4132
<br /> 165 Flanders Read 3555 . Hammer Ln.
<br /> G ftfr�PFg ough, MA 01581 Stockton, C�► 95219
<br /> e,Transporter 1,Company Name U.S.EPA ID Number
<br /> BFLSHiRE` CA1111,00 0 183 91
<br /> 7,Transporter 2 Company Name U,S,EPA ID Number
<br /> 8.Designated Faclllty,Name and Site Address U,S,EPA ID Number
<br /> U.;S. Ecology, Nevada Operations X V T 3 300100 0 0"
<br /> Highway 95, 11 miles S. of 'Beatty
<br /> .NV 89003 (775) 553-2263
<br /> 9a. 9b,U.S.DOT.Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes
<br /> HM end Packing Group(If any)) No. Type Quantity WI,NoI.
<br /> 0 1, Ikon-•RCRA Hazardous Waste, Solid (&R(; f171) DM P 352 *0018
<br /> I— +(page absorbent, a debris impacted with
<br /> Petro sum hydrocarbons)
<br /> z 2,
<br /> LU
<br /> C7
<br /> 3.
<br /> 4.
<br /> 14.Special Handling Instructions and Additional Information p
<br /> WAR.UL APPROPRIATE BESI : 3 5 3 0 6 5
<br /> Generator is RCnA v SQG an defined in p&RBdL PRM&CTIVL
<br /> Io ceR 260.10. 0018 coda represents CLOITHIUe, QUIKSTOP CCN: 659237
<br /> waste that is RCRA identified but notam reau lated. PROFILE # 070214257-0 1 ;16.. . NERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and a ciassl8ed,packaged,
<br /> marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations,If export shlpment and I am the Primary
<br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br /> I certify that the waste minimization statement Identified In 40 CFR 26227(a)(If I am a large uantity generator)or(b)(III am a small quantity generator)Is true,
<br /> Generat6eslOfferor's PrinteFyped Name Signature Month Day Year
<br /> J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexlt:
<br /> Transporter signature(for exports only). Date leaving U,S,:
<br /> W 17,Transporter Acknowledgment of Receipt of Materials
<br /> LU
<br /> Transporter 1 Printed ped Name Signature Month. Day Year
<br /> Transporter 2 PrintedlTyped Name Signature Month Day Year
<br /> 18.Discrepancy
<br /> ,18a,Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Parllal Rejection ❑Full Rejection
<br /> r Manifest Reference Number: .
<br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number
<br /> LL Facility's Phone:
<br /> W 18c,Signature of Alternate Facility(or Generatdr) 7 Month Day Year
<br /> 19 Hazardous Waste Report.Management Method Codes(I,e„codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 0
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a
<br /> PrintedlTyp fir,
<br /> ,
<br /> ed Name Signature ' ; Mopth D eeC
<br /> � >' tilal
<br /> \
<br /> EPA Form 8700.22(Rev,12.17).Previous editions are obsole e, TRANSPORTER COPY.
<br />
|