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Please print or type: Form Approved"OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Pa e 1 of 3.Emer ehcy Response Phone 4.Manifest Tracking Number WASTE MANIFEST c A L 0 0 0 0 4 3 3 41 (8 9300 019333518 F L E 5.Genera or's game and Mailing Ad ress nelr's t Addres ' diff rent han mat address 16 �C 1tap rn kets, Inc. � n. > 132 iss 5h.asndaars Roae� i9 Vestborotlgh, NA 01581 ` Generator's Phone: (510) 445-2282 6.Transporter 1 Company Name U.S,EPA ID Number BELSHIRS CaAO 0 0193913 . 7.Transporter 2 Company Name, U.S.EPA ID Number 8.Desi nated Facility Name and Site Address U.S.EPA ID Num r U.�. Ecology, Nevada Operations NV J 3 0 010 0 00 Highway 95, 11 miles S. of Beatty Beatty, NY 89003 (775) 553-2201 Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. Nat:-I11111M Hazardous ate, Solid (06 #171) LK P 352 *D01 o: _ __ �.�m) to acted with z 2. 001 L7 3. 4, 14,Special Handling Instructions and Additional Information UM AU BE3I= 37 0 60 4 Glemwator is a FAMA V9W as defined in 40 CFR 260.10. 0018 code represetrts CURSM. yutXKW OG7tt 659237 waste that is WMA identified but not PAOMZ # 070214257-0 RCRA regulated. 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferor's PnntedlTyped Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year a M� 1 Z Z Transporter 2 Printed Typed Name Signature Month Day Year F . 18.Discrepancy 18a.Discrepancy Indication Space ❑ QuantityType ❑ yp ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J tU LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous'waste treatment,disposal,and recycling systems) G 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1.5a Printedffyped Name Signature Ir r yT Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. TRANSPORTER COPY 1.32/3692130